m 






PRINCIPLES AND METHODS 



OF 



ORTHODONTICS 



AN INTRODUCTORY STUDY OF THE ART 

FOR STUDENTS AND PRACTITIONERS 

OF DENTISTRY 



BY 



B. E. LISCHER, D.M.D. 

PROFESSOR OF ORTHODONTICS, WASHINGTON UNIVERSITY DENTAL SCHOOL; MEMBER 

OF THE AMERICAN SOCIETY OF ORTHODONTISTS; AUTHOR OF 

" ELEMENTS OF ORTHODONTIA," ETC. 



ILLUSTRATED WITH 248 ENGRAVINGS 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 

1912 



^ 






V 



Entered according to the Act of Congress, in the year 1912, by 

LEA & FEBIGER 
in the Office of the Librarian of Congress. All rights reserved. 



p * 

ECI.A309351 



PEEFACE 



The introductory study of the art here offered to students 
and practitioners of dentistry was begun with the intention 
of furnishing a plain statement of present-day tendencies. 
But the author soon found it impossible to proceed with- 
out adopting a point of view which implied a more or 
less "independent reconstruction of the existing situation." 
This necessitated the omission of details which, historically 
at least, are of great significance. 

Many of the fundamental facts of the science (which 
have been appropriated from such cognate studies as 
anatomy) have likewise been omitted, on the assumption 
that every student has had adequate previous training in 
them. Similarly was it deemed advisable to eliminate the 
description of such technical phases as plaster model con- 
struction, details of soldering, etc., with which every dentist 
is conversant and which rightfully belong to the laboratory 
course. Nor has there been any attempt made to present 
the more recent discussions and debates with which our 
journal literature abounds. The dental school course does 
not permit of, nor does the beginner require, such minute 
exposition of the subject. In brief, the author presents the 
volume in that limited sense which its subtitle implies, and 
with the hope that its pages will prove both interesting and 
instructive. 



VI PREFACE 

The author desires to express his thanks to the publishers 
for the many courtesies shown him during the preparation 
of the volume; to other publishers and authors for the use 
of several cuts; and to his friend and collaborator, Dr. 
M. N. Federspiel, of Milwaukee, for his valuable counsel. 

B. E. L. 

Washington University Dental School. 
St. Louis 1912. 



CONTENTS 



INTRODUCTION 

CHAPTER I 

THE STUDY OF ORTHODONTICS 

Definition and Scope of Orthodontics 17 

The Literature of Orthodontics 20 

The Practice of Orthodontics 23 

The Technique of Orthodontics 20 



PART I 
PRINCIPLES OF TREATMENT 

CHAPTER II 

PREPARING THE MOUTH FOR TREATMENT 

Examination of the Patient 32 

The Relief of Pain 35 

Cleansing the Teeth . 36 

Instruction in Oral Hygiene 37 

Treatment of Caries 38 

The Extraction of Teeth 40 

CHAPTER III 

KEEPING RECORDS OF THE TREATMENT 

Written Records 43 

Plaster Models 46 

Photographs 49 

Radiographs 50 



viii CONTENTS 

CHAPTER IV 

THE ETIOLOGY OF MALOCCLUSION 

Definition 52 

Classification of the Factors 52 

Intrinsic Factors 55 

Extrinsic Factors 66 

Unknown Factors 77 

CHAPTER V 

THE DIAGNOSIS OF MALOCCLUSION 

First Principles 80 

Definition 83 

General Outline of the Anomalies of Dentition 84 

Differentiation of the Various Forms 85 

Summary 96 

CHAPTER VI 

FACIAL DEFORMITIES DUE TO MALOCCLUSION 

Normal Variations of the Head Form 97 

Abnormal Variations of the Profile 108 

Orthodontic Conceptions and. Ideals 118 

Diagnostic Methods 126 

CHAPTER VII 

THE PROGNOSIS OF MALOCCLUSION 

Definition 130 

General Considerations 131 

Special Considerations 133 

Clinical Summary 138 

CHAPTER VIII 

THE EVOLUTION OF METHODS 

Methods of the Past 144 

Rise of the Systems 148 

Lines of Advance 151 

Details of Design 152 



CONTENTS ix 
CHAPTER IX 

PRINCIPAL ELEMENTS OF MODERN METHODS - 

The Plain Band . 154 

The Anchor Band 156 

The Alignment Wire 159 

Ligatures and Elastics . 162 

Miscellaneous Accessories 163 

CHAPTER X 

PRINCIPLES OF APPLICATION 

Forms of Anchorage 164 

Stationary Anchorage 165 

Reciprocal Anchorage 166 

Intramaxillary Anchorage 167 

Intermaxillary Anchorage 168 

Extramaxillary Anchorage 170 

CHAPTER XI 

DETAILS OF APPLICATION 

The Anchor Band 173 

The Plain Band 175 

The Alignment Wire 176 

Ligatures and Elastics . 181 

CHAPTER XII 

PRINCIPLES OF RETENTION 

Tissue Changes Caused by Tooth Movement 183 

Definition of Retention 184 

Maintenance of Tooth Position 186 

Maintenance of Arch Form 187 

Maintenance of Arch Relation .189 



x CONTENTS 

PART II 
METHODS OF TREATMENT 

CHAPTER XIII 

TREATMENT OF MALPOSITION OF THE TEETH 

Labio version and Buccoversion 191 

Linguoversion 195 

Distoversion 198 

Mesioversion 201 

CHAPTER XIV 

TREATMENT OF MALPOSITION (CONTINUED) 

Torsoversion 203 

Infraversion 208 

Supraversion 210 

Perversion and Transversion 212 

CHAPTER XV 

TREATMENT OF NEUTROCLUSION 

Simple Neutroclusion 213 

Complex Neutroclusion 226 

CHAPTER XVI 

TREATMENT OF DISTOCLUSION 

Bilateral Distoclusion 245 

Unilateral Distoclusion 265 

CHAPTER XVII 

TREATMENT OF MESIOCLUSION 

Bilateral Mesioclusion 272 

Unilateral Mesioclusion 281 

CHAPTER XVIII 

TREATMENT OF MALFORMATIONS OF THE JAWS . . 284 



ORTHODONTICS 



INTRODUCTION 



CHAPTER I 

THE STUDY OF ORTHODONTICS 

DEFINITION AND SCOPE OF ORTHODONTICS 

Orthodontics is a term proposed by Sir James Murray, 
the eminent philologist, to cover that branch of dentistry 
which deals with the principles and practices involved in the 
prevention and correction of malocclusion of the teeth, and such 
other malformations and abnormalities as may be associated 
therewith. Dr. Frederick B. Noyes 1 defines it as "the 
study of the relation of the teeth to the development of the 
face, and the correction of arrested and perverted develop- 
ment." It is of dental origin, having been reared by dental 
practitioners, and is a crowning achievement of the dental 
progress of the last generation. The terms Orthodontia, 
Odontorthosia, Dental Orthopedics, and Dental Orthomorphia, 
which are less acceptable from a linguistic standpoint, are 

1 The Dental Cosmos, January, 1911. 



18 THE STUDY OF ORTHODONTICS 

also used. Like general dentistry, orthodontics is a part 
of the vast field of medicine, and when we recall "that all 
sciences which deal with life, with force, and with chemical 
composition" enter into the study of medicine, we may 
fairly comprehend the breadth of its base. 

Orthodontics as a Science. — As a science it is closely 
related to many of the medical sciences, the basis of which 
is biology, the science of life. "Life, that strange, unknown 
something which flies through the viewless air, flashes through 
the ocean's depths, blushes in the petals of a rose, and mani- 
fests itself in thousands of marvellous forms — can science 
grasp, define, or explain it?" In the present stage of our 
knowledge probably not completely; but it teaches us that 
all vital processes, including man and all his characteristics, 
as well as those of all other species, are the result of the 
interaction of certain laws. To define these laws, to test 
them in the crucible of observation and experiment, and 
then to express them in terms of human experience — this is 
the mission of science. 

Now, the treatment of dental anomalies involves us in 
countless difficulties, hence "we seek truth not merely for 
the pleasure of knowing, but in order to have a lamp for 
our feet. We toil at building sound theory in order that we 
may know what to do and what to avoid." Thus the process 
of dentition, its mechanism, causes, and various develop- 
mental stages, as exemplified by comparative studies, is not 
without meaning, but furnishes a field of compelling interest 
to every intelligent dentist. It is further apparent that a 
comprehensive knowledge of the development of the jaws, and 
of the nasal passages and their accessory sinuses (which are 
so intimately related to them), is also desirable. A frequent 
attribute of malocclusion of the teeth is a marked in harmony 



DEFINITION AND SCOPE OF ORTHODONTICS 19 

of the facial lines. The true basis of a differential classi- 
fication of such deformities is a wide familiarity with ethnic 
variations of the head form. A valuable aid in the study of 
the various forms of malocclusion of the teeth is an inquiry 
into the classification of all anomalies, the relations of 
anomalies to disease, and the foundations of teratology in 
general. Again, a consideration of the causative factors 
opens a large field of inquiry to the student of orthodontics, 
owing to their intimate connection with the theories of inheri- 
tance, the transmission of acquired characters, and other allied 
Darwinian factors and biological problems. Another essen- 
tial to a scientific comprehension of treatment is a careful 
consideration of the tissues of attachment, i. e., the alveolus 
and pericementum, and the changes they undergo during and 
after tooth movement. 

All these are questions for the scientific orthodontist to 
investigate, and, if possible, to explain; he must search for 
the laws underlying them, tell why they are so, and indi- 
cate the place they occupy in the scheme of things. Finally, 
to render our studies less difficult, and to perfect the nomen- 
clature of orthodontics, we must strive to develop a greater 
accuracy of expression and uniformity of usage of the terms 
we employ in our speech. 

The practice of medicine, in any of its branches, consti- 
tutes a remedial art; for art consists in doing, in the appli- 
cation of knowledge. "The subject matter of art is life, 
life as actually is; but the function of art is to make life 
better. Operations become arts when their purpose is 
conscious and their method teachable." , 

Orthodontics as an Art. — As an art, orthodontics is con- 
cerned with the principles and methods of treatment; what 
these are the present volume briefly tries to show. 



20 THE STUDY OF ORTHODONTICS 



THE LITERATURE OF ORTHODONTICS 

All endeavors to find adequate treatment of our subject 
in the earliest historic times have been fruitless. Thus, 
Farrar 1 writes of a review by Litch (1839), based upon some 
four hundred works on dentistry, and all they contained 
relating to the subject could have been gathered in one 
volume of moderate size. And though Celsus (a.d. 30) is 
said to have recommended finger pressure for the correction 
of malposition of the teeth, we can find no attempts at 
systematic treatment of the subject until the publication 
of Fauchard's 2 admirable book. The work of this eminent 
pioneer was not exclusively devoted to orthodontics, but he 
regarded the subject of sufficient importance to describe 
various methods of treatment and to dwell upon the etiology 
of malocclusion. 

The earliest recorded special work is that by the German 
dentist, F. C. Kniesel, entitled Der S chief stand der Zahne, 
in the German and French languages, and published in 
Berlin in 1836. During the interval embraced by the dates 
of publication of these two books the field of orthodontics 
was variously treated by dental authors, notable among 
whom were Bunon (1742), Bourdet (1757), Berdmore (1770), 
Fox (1803), Delabarre (1806), and Catalan (1808). The 
joint treatment of its subject matter with other phases of 
dentistry continued the prevailing custom for many decades, 
in fact, up to the present. Among the more prominent 
dental texts that continued thus to treat it are the following : 
Handbuch der Zahnheilkunde, Linderer, 1842; System atisches 

1 Irregularities of the Teeth, vol. i, p. 12. 

2 Le chirurgien dentiste, Paris, 1728. 



THE LITERATURE OF ORTHODONTICS 21 

Handbuch der Zahnheilkunde , Carabelli, 1844; American 
System of Dentistry, vol. ii, Litch — Guilford, 1887; American 
Text-book of Operative Dentistry, Kirk — Angle and Case, 
fourth edition, 1911; Dental Surgery, Tomes, fifth edition, 
1906; A Text-book of Operative Dentistry, Johnson — Pullen, 
1908. 

In 1880 Dr. Xorman Kingsley, of New York, published 
the first American text on orthodontics, entitled Oral 
Deformities. The volume embraced several chapters on 
malocclusion of the teeth, their etiology, diagnosis, and 
treatment; besides a consideration of cleft palates and 
fractures of the maxillae and their treatment. 

In 1888 appeared the two- volume work of Dr. J. N. 
Farrar, of Xew York, entitled Irregularities of the Teeth. 
These volumes are a veritable mine of orthodontic data, 
and cannot be otherwise regarded than epoch-making. 1 
This eminent pathfinder of the art was the founder not 
only of the "systems/ 1 but of present-day methods of 
treatment. 

In the meantime, general dentistry was making rapid 
progress; every department was being influenced by the 
vast extension of human knowledge during the last half of 
the nineteenth century. The growth of dental literature 
was now to proceed, and orthodontics claimed many enthusi- 
astic workers. It will be convenient to arrange all recent 
writers according to nationality, and by continuing our 
discussion of American authors we come to the work of 
Talbot, Irregularities of the Teeth, fourth edition, 1901. The 
book is said by its author to be " an outgrowth of researches 
which tended to oppose the too prevalent theory that irregu- 
larities of the teeth and jaws were the result of local, not 

1 Pfaff, Lehrbuch der Orthodontie, 2d ed., p. 373. 



22 THE STUDY OF ORTHODONTICS 

constitutional causes." Most of us believe this to be 
extreme teaching; but it should be read, owing to its treat- 
ment of the subject of degeneracy. Orthodontia, by S. H. 
Guilford, fourth edition, 1905, has been a favorite intro- 
duction for many years Malocclusion of the Teeth, by E. H. 
Angle, seventh edition, 1907, is an exposition of the Angle 
System, and, like other works published in the last decade, 
open to criticism because of its exclusive originality of 
presentation. The works of Knapp, Orthodontia Practically 
Treated, 1904; of Jackson, Orthodontia and Orthopedia of 
the Face, 1904; and of Case, Dental Orthopedia, 1908, are 
treatises of the same group, each volume being a presentation 
of the author's methods. These remarks, however, are not 
intended as an index of the relative value of these works, 
since they contain much that the student cannot afford 
to ignore. The work by MacDowell, Orthodontia, 1901, 
concludes the list of American authors. 

The foreign literature, though not so large, is a creditable 
showing for a specialty as young as orthodontics. In 
England there is the excellent little volume of essays by 
Wallace, entitled Irregularities of the Teeth, 1904; and the 
more pretentious text by Colyer, of the same title, published 
in 1900. 

In Germany there is the work of WalkhofT, Die Unregel- 
massigkeiten in den Zahnstellungen und Ihre Behandlung 
(1891), and the texts by Jung (1906), PfafT (second edition, 
1908), Herbst (1910), and the excellent little manual by 
Korbitz (second edition, 1911). 

In France the art is represented by the works of Gaillard 
(1909), Martinier (1903), and Donogier (1895). Spanish 
dentists have recently (1909) welcomed a work by Subirana, 
entitled Anomalies de la Oclnsion dentaria y Ortodoncia. 



THE PRACTICE OF ORTHODONTICS 23 

Controversial writings, the reports of cases, and modi- 
fications of technical details (whose proper place is in the 
journals) have been liberally presented by dental maga- 
zines, many of them conducting departments of orthodon- 
tics. 1 In Germany a monthly journal exclusively devoted 
to the art has recently (1907) been established, entitled 
Zeitschrift fur Zahnarztliche Orthopadie . 

Much of the recent periodical literature represents the 
proceedings of societies and scientific associations. In the 
general bodies, such as State, national, and international 
societies, sections are frequently organized for the more 
deliberate consideration of orthodontic problems. Among 
the societies exclusively devoted to orthodontics, mention 
may be made of the American Society of Orthodontists, 
the British Society for the Study of Orthodontics, and the 
Deutschen Gesellschaft fur Orthodontie, etc. 

Thus the art, though hardly out of its teens, has, never- 
theless, an extensive library; and at its present rate of growth 
bids fair to equal in content, as well as in volume, the liter- 
ature of other branches of dentistry. The recent proposal 
of A. D. Black 2 that the profession adopt the Dewey decimal 
system of classification for dental literature will render 
available the countless articles in our magazines, covering 
every phase of the sub ect. 



THE PRACTICE OF ORTHODONTICS 

Recent advances in the methodology of the art and the 
consequent extension of its boundary lines have abundantly 

1 Items of Interest, New York. 

2 Proc. Inst. Dent. Pedagogics, Sixteenth Annual Report. 



24 THE STUDY OF ORTHODONTICS 

justified its separation from general practice in all com- 
munities capable of supporting the specialist. The many 
advantages of specialization are so well known that a 
restatement of them here is deemed unnecessary. Ortho- 
dontic services by their very nature readily constitute a 
special and ample field. Hence the point we wish here 
to emphasize is the dependence and independence of the 
two fields, their limitations and relations, and to indicate 
the course one ought to follow if one contemplates the 
practice of orthodontics. This theme has been the subject 
for numerous articles in the journals, though rarely has it 
been so ably presented as in the paper by Dr. Ottolengui, 
entitled "The Sphere of the Dentist in the Field of Ortho- 
dontia," from which we quote the following: 1 

"I respectfully submit it is my view that the best ortho- 
dontists of the future, as in the past, must be forthcoming 
from the ranks of such men as begin in the regular practice 
of dentistry, and gradually choose to practise orthodontia 
exclusively from a pure love of the work, and especially 
because of their inherent love for, and patience with, 
children. 

"If this be true, it follows as a logical sequence that the 
dentist has the moral as well as the legal right to practise 
orthodontia; but he should have no legal right, as surely he 
has no moral right, to undertake orthodontic work without 
a full and competent knowledge of the present requirements 
and technique. Any physician may treat the eye, the nose, 
the throat, or do any operation in surgery if he has the 
ability to do so successfully; but he may be mulcted in 
heavy damages if he attempt such work and fail, because of 

1 Items of Interest, November, 1909, p. 819. 



THE PRACTICE OF ORTHODONTICS 25 

lack of proper training or skill. The medical degree is no 
protection to the malpractitioner. 

" It is the same in dentistry. Any dentist may undertake 
the treatment of malocclusion, but he is guilty of malprac- 
tice in some degree if he does not first acquire the needed 
training and knowledge. 

" The sphere of the dentist in orthodontia is, therefore, to 
be considered from a dual aspect: (1) The general prac- 
titioner who elects to treat malocclusion occasionally, and 
(2) the dentist who decides to refer all such cases to the 
specialist. The first man should have exactly the same 
knowledge as the specialist himself. For, if the dentist treat 
but one case a year, he is morally bound to know how, or 
else refer the patient elsewhere. 

"On the other hand, the general practitioner who decides 
not to treat malocclusion, but elects to recommend a special- 
ist, should at least inform himself sufficiently of the art to be 
a competent judge of the success or failure of the specialist 
into whose hands he takes the responsibility of placing the 
management of the teeth and jaws of a growing child. For, 
it should be remembered, there are degrees of excellence in all 
crafts, and the mere fact that a man may announce that he 
has decided to 'restrict his practice to orthodontia' does not 
prove that he is competent." 

As an additional word of caution, it is well to state that 
no one should attempt the exclusive practice of orthodontics 
without adequate preliminary training in general dentistry, 
because a liberal knowledge in the treatment of the two 
main groups of oral diseases (i. e., caries and lesions of the 
pericementum, which can only be acquired in general prac- 
tice) is absolutely indispensable. It is imperative that we 
learn by experience what it means to keep a mouth well. 



26 THE STUDY OF ORTHODONTICS 

Finally, when combined with general dentistry (a neces- 
sity in all outlying districts and rural communities) it will 
be necessary to so systematize the office routine that a 
definite number of hours be exclusively devoted to its prac- 
tice. This should be regarded as a pleasant duty by all 
. conscientious dentists ; for it has been estimated that fully 
50 per cent, of the children in every community are afflicted 
with some form of malocclusion of the teeth, which, in the 
aggregate, means a vast army of countless thousands upon 
whom, for obvious reasons, the specialist can never smile. 
And last, but not least, the mastery of orthodontics implies 
postgraduate study, which the dental hospitals of our 
larger universities should liberally provide. Such depart- 
ments are worthy of the most liberal endowments, and it 
need hardly be emphasized that they should be open to 
graduate students the year around. 



THE TECHNIQUE OF ORTHODONTICS 

Many of the earlier works on general dentistry contained 
chapters on "Irregularities" and "Regulation," probably 
because the correction of malocclusion has always been 
regarded as a function of the dentist. A noteworthy char- 
acteristic of these texts was the prominence given to the 
technical phases of the art, the details of appliance con- 
struction being constantly kept in the foreground. The 
treatment of malocclusion being a mechanical process, in 
which technical methods play an exceedingly important 
part, it seems quite natural that the technique should have 
been regarded as an important division. Indeed, it is still 
so regarded; but the dawn of another era is upon us, the 



THE TECHNIQUE OF ORTHODONTICS 27 

day of "home-made" appliances is rapidly approaching its 
twilight, and an appreciation of greater possibilities is 
directing our attention and energy to other problems. The 
mechanisms of former days were usually manufactured by 
the operator, which consumed a great deal of his time, and 
so magnified the details of construction that the principles 
utilized were frequently lost sight of. 

The following prophecy from the pen of Dr. J. N. Farrar 1 
appeared in 1878: "Although the simplification of regula- 
tion has been a great desideratum for many years, it has for 
some time been evident to me (though by most people 
thought to be impracticable) that the time will come when 
the regulation process and the necessary apparatus will be so 
systematized and simplified that the latter will actually be 
kept in stock, in parts and in wholes, at dental depots, in 
readiness for the dental profession at large, so that it may be 
ordered by catalogue numbers to suit the needs of the case; so 
that by a few moments' work at the blowpipe in the labora- 
tory the dentist may be able, by uniting the parts, to pro- 
duce any apparatus, of any size desired, at minimum cost of 
time and money." 

That prediction has been fulfilled; orthodontics has 
passed through its elementary stages, and finally reached 
as high a degree of development as other departments of 
dentistry. There was a time when the operator made his 
pluggers and other instruments, and the prosthodontist his 
plate gold and solders ; similarly was it considered an ortho- 
dontist's duty to invent and construct the appliances for a 
case in hand. But after years of ceaseless toil, " of immeas- 
urable devotion of energy and time and genius" to a most 

1 The Dental Cosmos, January, 1878. 



28 THE STUDY OF ORTHODONTICS 

worthy art, certain facts of experience have finally been 
systematized. Indeed, the whole spirit of effort of the last 
decade has been a reaction against former methods, and 
has been characterized by a demand for a new arrange- 
ment, for some settled principles in the art. A mere heaping 
together of disconnected, confusing methods has long since 
ceased to satisfy all serious students. Thus, there comes the 
concession from all sides that appliances are but the means 
to an end — the remedies, as it were — with which the operator 
should so familiarize himself as to master their use and 
manner of application, not their manufacture. 

"Systems." — From the standpoint of this new and 
higher perspective, and in response to the urgent demands 
of progress, several so-called "systems" have been offered 
to the profession, every one of which embraces much that 
is good. But a system, at best, is but a compilation of 
certain definite principles, elements of design, and methods of 
treatment, and these rarely are the product of a single mind. 
It usually represents the results of the separate efforts of 
several individuals, and may even be compiled for private 
gain. On the other hand, a system may have a higher motive, 
and tersely emphasize the advantages of simplicity of tech- 
nique, or the achievements of unusual skill. Doubtless their 
influence upon our technique has been salutary, though our 
resultant methods continue to impose definite technical 
attainments. Hence, laboratory courses in orthodontics, 
similar to those of operative and prosthetic dentistry, of 
chemistry and bacteriology, have become permanent fixtures 
in the dental curriculum. 1 The student frequently under- 
estimates the importance of this phase of the subject, and 

1 Lischer, Elements of Orthodontia, St. Louis, 1909. 



THE TECHNIQUE OF ORTHODONTICS 29 

defers its accomplishments until launched in private prac- 
tice; when the demands of a growing patronage and the 
unavoidable difficulties of treatment militate against the 
acquirement of that special dexterity so essential to success. 
Moreover, it is immaterial which method of treatment an 
operator will ultimately adopt — whether it be a system as 
such, or a combination of several — the technical training 
enjoined in either case will always be considerable. Thus, 
the application of appliances for treatment, the accepted 
methods of keeping records, and the construction of reten- 
tion appliances demand a very high order of skill; and one 
arrives at skill only by patient labor, by the practice of an 
exacting discipline. Let every student of orthodontics 
remember, therefore, that the laboratory course is always 
designed for a definite purpose, that it fits well into the 
plan of things, and that there is no short cut across the 
plane of accomplishment. 



PART I 
PRINCIPLES OF TREATMENT 



CHAPTER II 
PREPARING THE MOUTH FOR TREATMENT 

Surgical cleanliness on the part of the operator and his 
equipment is the first rule in all operative procedures. Since 
the founding of bacteriology by Pasteur, and its wonderful 
development by medical scientists, leading to the discovery 
of the relations of bacteria to animals in health and disease, 
it has received a new interpretation. Were it not for the 
fact that its omission continues the prevailing custom with 
far too many operators, it would not receive mention here. 
Indeed, its presentation is hardly appropriate in a work on 
orthodontics. 

Following the reception of the patient, the adjustment 
of the operating chair and its accessories, should come the 
preparation of*the field of operation. In orthodontic prac- 
tice this has a special significarce, and embraces a number 
of important preliminary considerations. The aim of these 
several preliminary details is the establishment of oral 
health — in so far as this is possible prior to orthodontic 
treatment — and to facilitate the treatment. 



32 PREPARING THE MOUTH FOR TREATMENT 



EXAMINATION OF THE PATIENT 

The fundamental importance of a careful examination of 
every individual applying for treatment need hardly be 
emphasized, for it forms the very basis of every intelligent 
diagnosis. A cursory consideration of the general health 
and physical development of the patient constitutes the first 
step of such examination. Should any doubt regarding it 
arise, the patient (or parent) should be questioned and a 
record made of recent recovery from serious ailment. Such 
interrogations frequently prompt parents to relate the pres- 
ence (or removal) of adenoids, and other conditions etio- 
logically connected with the malocclusion. The attention 
of the operator is commonly directed toward some "promi- 
nent" incisor or cuspid, which he will for the present ignore, 
and consider later in the course of a definite routine. 

The thorough examination of the oral cavity should now 
proceed, and include, besides the superior pharynx, the nasal 
passages and form of the nose; the function of the lips; the 
facial lines and expression; the jaws beyond the immediate 
alveoli; the relative immunity or susceptibility to caries; 
the condition of the gums and pericementa; the form of 
the palate ; the f rena of the lips and tongue ; and all surfaces 
of the crowns of all teeth. Though a differential diagnosis 
of the malocclusion suggests itself here, it is usually best to 
defer the same until accurate models have been constructed. 

Instruments. — The instruments required for an examina- 
tion consist of a mouth mhror (Fig. 1), of non-magnifying 
type, with metal handle. A plain, long-handled exploring 
instrument, of a pattern as shown in Fig. 2, is used for the 
location and exploration of carious cavities. The use of 



EXAMINATION OF THE PATIENT 33 



Fig. 1 



Fig. 2 




Mouth mirror. 



Exploring installment. 



34 



PREPARING THE MOUTH FOR TREATMENT 



floss silk in the interproximal spaces and contact areas is 
also advised. A tongue depressor of simple design (Fig. 3) is 
used for the examination of the superior pharynx. Patho- 
logical conditions of the nasal passages which may stand in 
causal relation to the malocclusion and require the services 



Fig. 3 



Fig. 4 





Tongue depressor. 



Nasal speculum. 



of a rhinologist may frequently be detected with a nasal 
speculum (Fig. 4). A pair of operating pliers and some 
aseptic absorbent paper, for the drying of tooth surfaces, 
are useful accessories. All of these instruments should be 
in readiness upon the operating table, and all unnecessary 
appliances removed. Finally, a memorandum of all obser- 



THE RELIEF OF PAIN 35 

vations should be made upon a record card conveniently 
placed upon an adjoining table or desk. The form of this 
card is described in Chapter III. 



THE RELIEF OF PAIN 

The value of early treatment for malocclusion is increas- 
ingly being appreciated, hence many of the patients in an 
orthodontic practice are children in whose mouths temporary 
teeth are still present. And though the treatment of tem- 
porary teeth is more widely practised than formerly , extensive 
caries, pulp exposure, and its sequelw are all too frequently 
met with. The proper treatment of such conditions should 
invariably be insisted upon; and in this connection let it be 
remembered that reckless extraction is not the remedy. 
Indeed, the exigencies of many cases demand their conser- 
vation, especially if we view the denture as a whole, and 
always from an orthodontic standpoint. The disastrous 
results following the neglect and early loss of temporary 
teeth will be discussed in the chapter on Etiology. 

The temporary teeth are frequently the seat of pain, which 
many of the younger patients fail to mention. "In every 
instance where there is suffering the manifest duty of the 
professional man is to relieve it at once if possible, no matter 
in what form it may present itself " (Johnson). The sub- 
sequent application and operation of the appliances for 
tooth movement are of sufficient annoyance to make the 
above imperative. The student should therefore make a 
study of the causes of pain and of all therapeutic aids 
and methods employed for its alleviation. Such service is 
always appreciated, and goes far in the promotion of con- 
fidence. 



36 PREPARING THE MOUTH FOR TREATMENT 



CLEANSING THE TEETH 

Cleanliness and health are synonymous terms in oral 
hygiene, hence the next important preliminary consideration 
is a careful cleansing of the teeth. "Dentists are not living 
up to the highest possibilities of their art when they fail to 
consider the importance of maintaining the tissues around 
the teeth in a state of health, and this cannot be done short 
of a careful removal of all extraneous material which may 
be found adherent to the teeth." (Johnson.) Probably no 
two operators will exactly agree as to the instruments to be 
used and the particular methods to be followed in cleaning 
the teeth; but all must agree on the fundamental importance 
of the procedure. The author is not aware of any definite 
statistics regarding the matter, but he feels certain that only 
one patient in every hundred presenting themselves prac- 
tises oral hygiene to the extent that orthodontic treatment 
could be instituted without first cleansing the teeth. 

But aside from the beneficial effects upon the general 
health of the oral cavity which every cleaning promotes, it 
must further be emphasized that appliances are shortly to 
be adjusted. These are to be securely anchored to a number 
of teeth, and in many instances remain for a period of weeks, 
or even months. Upon their removal, after tooth movement 
has been accomplished, retention appliances are to be 
inserted for another prolonged period. Not infrequently the 
anchorage of the latter are upon the same teeth previously 
utilized. It is obvious, therefore, that only by the utmost 
cleanliness during the entire period of orthodontic treatment 
can the health of the oral cavity be maintained and caries 
of the teeth prevented. 



INSTRUCTION IN ORAL HYGIENE 



INSTRUCTION IN ORAL HYGIENE 

The maintenance of physical vigor is a duty of every 
human being, and implies the practice of a rigid personal 
hygiene. Among its many requirements few are of greater 
importance than the proper care of the mouth. The vast 
majority of individuals suffering from dental diseases is 
incompetent in the practice of an efficient oral hygiene; 
hence it becomes the duty of the operator carefully to instruct 
patients in this important detail. The most opportune time 
for this instruction is immediately after the teeth have been 
cleansed. It is an opportunity the conscientious practitioner 
never neglects, and it should always be regarded as an 
essential detail of a carefully planned routine, because all 
regulating appliances interfere with the normal functions 
of the mouth and favor the lodgement of food particles, thus 
promoting caries of the teeth. 

Owing to the rapid rise of orthodontics as a specialty, 
this discussion brings us to the line of demarcation between 
the fields of the specialist and general practitioner. An 
orthodontist extends his acquaintance and wins patronage 
in any one of three legitimate ways; patients are referred to 
him (a) by the family dentist, (b) by the family physician, 
or (c) by a member of the laity. Of course, if the ortho- 
dontic treatment is instituted by the family dentist there 
can be no question as to when, or how, and by whom these 
services are to be rendered — they belong to the general 
practitioner. On the other hand, if the specialist is consulted, 
or if the case is referred to him by the dentist, the entire 
treatment can be rendered with greater dispatch if both 
can agree on a definite plan, since all of these preliminary 



38 PREPARING THE MOUTH FOR TREATMENT 

services should always be rendered prior to any orthodontic 
treatment. But the specialist must not underestimate 
responsibilities during the period his services are being 
rendered, and in all cases showing a high degree of sus- 
ceptibility to caries he should encourage the most liberal 
consultation with the family dentist. 

TREATMENT OF CARIES 

All carious cavities, in both temporary and permanent 
teeth, should be treated prior to tooth movement and in the 

Fig. 5' 




Carious cavities rendered extremely inaccessible by the malocclusion. 

best manner the conditions will permit. The choice of a 
filling material is at times rendered difficult, since the factor 
of accessibility may enter into consideration. Fig. 5 shows 
an occlusal view of the upper arch of a patient, aged twelve 



TREATMENT OF CARIES 39 

years, with cavities in the right and left centrals and laterals 
as indicated by a and b. It is obvious that the insertion of 
gold foil or other permanent repair is out of the question. 
A plastic like oxyphosphate of zinc is here indicated, and 
will be protected by bands placed upon the teeth for their 
movement. After the orthodontic treatment has been 
completed they will be normally accessible, and will then 
permit of permanent restoration. 

In cases of extensive caries, requiring crowns and bridges, 
the operator must likewise come to a definite conclusion 
as to the most opportune time for their insertion. Accessi- 
bility, though still a factor, now gives way to anchorage; for 
should the affected tooth, or teeth, be required for anchorage 
of the regulating appliance, they should be restored before 
orthodontic treatment is attempted. Fortunately, the 
necessity for such extreme remedial measures is decreasing, 
and their consideration in orthodontic practice is becoming 
extremely rare. 

The author has recently treated a case of bilateral disto- 
clusion, accompanied by labioversion of the upper incisors, 
for a boy, aged twelve years, who, owing to an accident result- 
ing in fracture, had a porcelain crown inserted upon the left 
upper central during his ninth year. 1 The behavior of the 
root during orthodontic treatment did not appreciably 
differ from those in which the pulps were vital. Numerous 
similar experiences, therefore, predicate the conclusion that 
if caries has progressed so as to affect the pulp, or to a stage 
demanding an artificial crown, it should receive the custom- 
ary treatment; that non-accessibility, or extreme malposition, 
may occasionally postpone the more permanent restorations 
until tooth movements have been accomplished. 

i See Case K, Figs. 207 and 208. 



40 PREPARING THE MOUTH FOR TREATMENT 

THE EXTRACTION OF TEETH 

The subject of the extraction of teeth prior to or during 
orthodontic treatment divides itself into that (a) of tempor- 
ary teeth, (b) of supernumerary teeth, and (c) of permanent 
teeth. 

Temporary Teeth. — Temporary teeth too extensively 
decayed to warrant attempts at conservation, and whose 
retention would seriously affect the health of the oral cavity, 
should always be removed prior to treatment. But in many 
instances, especially in the very young, when several years 
might elapse before the eruption of their successors, every 
effort should be made to retain them. Again, in cases of 
arrested development or "contracted" arches, with firm 
temporary teeth present and postponement of treatment 
inadvisable, their movement and subsequent retention 
should proceed with that of adjacent permanent teeth to 
induce growth of the alveoli and jaws beyond, and to pro- 
mote the normal eruption of their successors. Extraction 
is indicated in every case of prolonged retention, provided 
there are no symptoms of deficiency in the number of perma- 
nent teeth, or where the successor is in process of eruption. 

Supernumerary Teeth. — Supernumerary teeth should always 
be extracted, especially when they operate as a cause of 
malocclusion. It is best, however, to defer all extractions 
until accurate models have been constructed. Every 
operator should strive to record as many cases as his 
practice affords. 

Permanent Teeth. — The extraction of permanent teeth for 
the facilitation of the orthodontic treatment is a question 
regarding which many incisive papers, and more incisive 
rejoinders, have been written. Prior to the development of 
our present methods for the correction of arch malrelation, 



THE EXTRACTION OF TEETH 41 

removal of certain permanent teeth was widely practised, 
even regarded as a necessity. But with the perfection of the 
details of arch movement as well as tooth movement, the 
group of cases in which extraction is now permissible has 
been greatly restricted. The literature pertaining to this 
subject is voluminous, immensely interesting, and of the 
utmost value, though the following two rules by Professor 
Guilford 1 serve as an excellent abbreviated version of the 
entire discussion. 

"1. Do not decide to extract until a careful study and 
restudy of the case have been made from articulated models 
and the patient in person, and until every available method 
of procedure without extraction has been carefully con- 
sidered." 

"2. If extraction seems unavoidable, adopt the best 
method of correction without it, and when, in the course 
of the operation, it becomes absolutely evident that the 
desired result cannot be obtained in that way, it will still 
be time to extract and change our method of procedure." 

Finally, it must ever be remembered that the loss of even 
a single tooth produces a break in the continuity of the arch ; 
that the adjoining teeth always tend to move toward the 
space thus created; that the abnormal inclination of the 
adjacent teeth is accompanied by loss of contact in more 
remote places in the arch; that a reduction in the size of the 
lower arch is frequently followed by a deepening of the " bite" 
and an increase in the difficulties of retention; and that the 
harmony of facial form rarely permits of the sacrifice. The 
numerous clinical phases of this subject can be more appro- 
priately dealt with in subsequent chapters on the methods of 
treatment. 

1 Orthodontia, 4th ed., p. 48. 



CHAPTER III 
KEEPING RECORDS OF THE TREATMENT 

Many of the advances in medical practice have been based 
upon hospital statistics, where the facilities and methods 
for keeping records have always surpassed those adopted by 
individual practitioners. It is, perhaps, not inaccurate to 
state that in dentistry the reverse is true. Dental clinics, 
in most instances, are usually conducted for the purpose of 
furnishing opportunities for experience to students and to 
serve those in need, being only incidentally utilized as centres 
of research. It is but fair to add, however, that the hospitals 
furnishing the largest and most trustworthy mass of clinical 
data for medicine are not, necessarily, the school hospitals; 
and that the funds at the command of such institutions far 
exceed those of the dental infirmaries. For purposes of 
scientific research it is always advisable to procure clinical 
data from both public and private records, though under 
existing dental conditions the private records of practitioners 
are preferable. It is to be hoped that an enlightened interest 
in human health and an appreciation of the sociological 
significance of preventive medicine (which should be provided 
for all the people by the strong arm of the State) will revolu- 
tionize this phase of dental service in the not distant future. 

Now, it is not at all unusual for an average practice to 
extend over a period of from thirty to forty years, thus 
affording ample opportunities for the compilation of valuable 



WRITTEN RECORDS 43 

data upon which scientific deductions and advances in 
treatment can be based. It is exceedingly important, there- 
fore, that the beginner adopt some plan for the keeping of 
records, and the points to be emphasized are that such 
records should be accurate, concise, and practical. When 
they comply with these requirements, their value can hardly 
be overestimated. They should be so designed as to provide 
for the special needs of an orthodontic practice, which may 
briefly be enumerated as consisting of written records, of 
plaster models, of photographs and radiographs, and such 
illustrations or appliances as are deemed worth recording. 



WRITTEN RECORDS 

Among the many methods that can be employed for the 
keeping of written records, a specially designed card system 
has been found most convenient. It should be of standard 
size, preferably 5x8 inches, and provided with a filing 
cabinet so arranged as to permit of comprehensive classifi- 
cations. Figs. 6 and 7 exhibit the essential items of such a 
record card. All of the scientific phases of a case, including 
the patient's name and the case number, are placed upon 
the face of the card. The reverse side is arranged for the 
practical phases of the treatment. Several of the items upon 
the front of the card are compiled from the reverse side after 
completion of the case, or at the operator's convenience. In 
addition, the author uses plain ruled cards of the same size as 
the record for the compilation of all data of scientific interest. 
These are reclassified by the use of extra guides, and can 
be compiled by any competent assistant. 



44 



KEEPING RECORDS OF THE TREATMENT 



WRITTEN RECORDS 



45 



H z 

2 o 



46 KEEPING RECORDS OF THE TREATMENT 

This system of records renders available for immediate 
use or study all the material his practice affords. For 
example, it enables one to instantly state the number of 
patients of any given age, or sex; the number of cases where 
the influence of a given etiological factor is exhibited in the 
models, e. g., premature loss of temporary teeth. All models, 
photographs, radiographs, etc., are numbered and recorded 
on the record card. Thus all items of interest of any given 
case, or of a series of cases, can instantly be brought together 
for comparison and study. 

The possibilities of the card system are so numerous that 
it appeals to every operator who values his records at their 
true worth ; it is so elastic in its application that any inquiry 
or investigation may easily be carried out by its use. 



PLASTER MODELS 

In 1756 Ph. Pfaff * introduced the use of plaster of Paris 
for model construction. That its use did not become 
general, however, is evinced by the fact that Kneisel, 2 eighty 
years later, still relied on sulphur, though both employed 
wax as an impression material. The latter frequently 
resorted to the use of metallic models in the construction 
of his appliances. These were made of fusible alloy and 
obtained from plaster impressions of his sulphur models. 

The construction of accurate plaster models of the upper 
and lower teeth and adjacent parts is now considered a 
necessary detail of every orthodontic record (Fig. 8), and, 
as Angle has clearly emphasized, their value is enhanced in 

1 Zahne des Menschl. Korpers, Berlin. 

2 Der Schiefstand der Zahne, Berlin, 1836. 



PLASTER MODELS 



47 



proportion to their accuracy. To obtain this accuracy 
plaster should invariably be used for the impression from 
which the model is made. When accompanied by written 
records, they are of the greatest scientific value, especially 
to the owner who is familiar with many of the unrecorded 
details of their history. 

Fig. 8 




A plaster model of a case of malocclusion prior to treatment. 



Clean, perfect models are an incentive to render better 
service and mark the dividing line between the amateur 
and artist. They are absolutely necessary in making an 
intelligent diagnosis; are useful in a study of the etiology 
and prognosis; and particularly in planning the treatment 
and designing the retention appliances. Tooth movement 
usually extends over a period of several months, and is only 



48 



KEEPING RECORDS OF THE TREATMENT 



ultimately successful if adequate retention is provided. The 
latter is an extremely difficult phase of every treatment, and 
is practically impossible without the aid of accurate models 
of the original conditions. No operator can afford to rely 
on his memory as to the exact nature of these original 
conditions. 

Facial deformities are frequently due to anomalies of 
dentition, and their correction now occupies a large place 
in orthodontic practice. A record of such service, for which 



Fig. 9 




Plaster models of the face before and after treatment. (After Case.) 

two methods are at our disposal, is eminently desirable. 
Professor Case 1 recommends plaster models of the facial 
lines. These may be made in full front and profile views, 
and are of natural size (Fig. 9). But the construction and 
filing of these models present difficulties which many 
operators have sought to avoid. This has given rise to the 



Dental Orthopedia, Chicago, 1908. 



PHOTOGRAPHS 49 

adoption of the photographic method, a process introduced 
by Professor John W. Draper, of the University of New 
York, in 1839. 

Fig. 10 




Shows size of the unmounted photographs and the lines to which they are cut before 
mounting on the record cards. 



PHOTOGRAPHS 

When made according to certain definite requirements, 
photographic records of the facial lines answer every pur- 
pose, and for convenience are mounted on cards of the same 
size as the record. The requirements are simply these: 
The same photographer should make all photographs of 
4 



50 KEEPING RECORDS OF THE TREATMENT 

any given series; he should use the same lens in every case 
and adopt a uniform size and pose. The prints should 
always be made upon the same kind of permanent paper, 
and delivered unmounted. A good plan is to instruct the 
photographer as to what is wanted, laying special emphasis 
upon the fact that under no circumstances shall he retouch 
any of the operator's negatives. 

To avoid variation in size, particularly in the various 
prints of any given case, the author has taken the precaution 
to provide the photographer with a card upon which accurate 
measurements are marked. It is advisable further to agree 
on the kind of background to be used, a dark ground being 
usually best, because it affords the proper contrast. 

In mounting, many of the unnecessary features of the 
prints (such as dress, shoulders, hair ornaments, etc.) may 
be eliminated by using a pattern cut from transparent 
celluloid, and marking to exact size before cutting (Fig. 10). 
All prints of any given case may then be mounted upon a 5 x 8 
card, numbered and filed in the cabinet with the records. 

RADIOGRAPHS 

In the treatment of malocclusion of the teeth one fre- 
quently meets with anomalies of number, or of eruption and 
form. To establish certainty in the diagnosis of such cases 
the cc-rays (discovered by Professor Rontgen in 1895), in com- 
bination with photographs, are of the greatest value. Indeed, 
for the elimination of guesswork they are invaluable, since 
by their use it is possible to determine definitely deficiency 
or redundancy in the number of teeth, and to ascertain 
the peculiarities of anomalies of form and eruption. The 
difficulties encountered in the movement of teeth may at 



RADIOGRAPHS 51 

times be due to the fusion or malformation of their roots; 
tardy eruption may occasionally be caused by perverted 
position; a negative or indefinite history of premature 
extraction rendered intelligible, instead of construed into 

Fig. 11 







T 





Shows tardy eruption of the right central incisor due to the supernumerary tooth 
shown in Fig. 12. 



Fig. 12 




Radiograph of case shown in Fig. 11. 

deficiency of number. Many cases might here be introduced 
to illustrate the wide range of their usefulness, but Figs. 
11 and 12 will suffice, for they clearly show the presence of a 
supernumerary tooth as the cause of tardy eruption of the 
right upper central incisor in a girl, aged eleven years. 



CHAPTER IV 

THE ETIOLOGY OF MALOCCLUSION 

Definition. — In medical science, the study of the origin of 
disease and abnormality is termed etiology. It embraces a 
consideration of all causative factors, and of the provisional 
theories advocated when the causes remain obscure. And 
since it is the mission of orthodontics to prevent, as well 
as correct, certain anomalies of dentition, it is obvious that 
all knowledge relative to their causation is of the very first 
importance. From time immemorial, therefore, observant 
operators have endeavored to ascertain and remove these 
agencies, believing this to be the first aim of every rational 
treatment. Unfortunately, this phase of the art frequently 
presents problems exceedingly difficult of solution. 

CLASSIFICATION OF THE FACTORS 

In order to diminish these difficulties, several authors 
have attempted a classification of the etiological factors; 
though a review of the literatur pertaining to this subject 
impresses one with the fact that a quite general disagreement 
yet exists. Some writers accept the time-honored division 
into hereditary and acquired, finding little difficulty in formu- 
lating definitions for these two terms. Others exhibit a very 
evident skepticism regarding the "influence of heredity," and 
thus lean strongly toward the acquired group. 



CLASSIFICATION OF THE FACTORS 53 

Heredity and Predisposition. — Of course, there was a time 
when heredity explained it all, when it served as a cloak 
for our ignorance; when most diseases and abnormalities 
were believed to have been transmitted from parents to 
offspring. But the physical basis of heredity (a mechanism 
existing within the germ cell) is now fairly well established. 
Many of the recent advances in biology have fostered a 
strong opposition to the old views, forcibly emphasizing the 
influence of environmental (acquired) factors, which cannot 
be ignored. "As to the inheritance of the effects of extrinsic 
forces upon the individual, we find little in the way of direct 
evidence. Mutilations of any sort are not inherited." 
(Jordan and Kellogg.) This new teaching, it must be 
admitted, has served as a healthy antidote; it was needed. 

On the other hand, the claim of the opponents of heredity 
— "that nature never transmits the abnormal/' that all 
anomalies are but the result of certain lapses in nature's 
processes, always due to local and extraneous influences — 
is equally untenable. In the light of modern biological 
science either view is now considered extreme. 

Unfortunately, in these days of the "systems," with their 
truly wonderful achievements in technique, we are prone 
to rest content with our superficial calculations— for we 
love to cling to seeming bounds. But accepting, as we must, 
the physicochemical explanation of life, we are constrained 
to adopt those causomechanical factors of its flux which are 
recognized by biologists generally, and which "involve no 
philosophical assumptions." These are heredity, variation, 
adaptation, selection, isolation, and (probably) mutation. 
With the first of these we are here briefly concerned. 

Heredity may be defined as "the genetic relation between 
successive generations, as the transference of similar char- 



54 THE ETIOLOGY OF MALOCCLUSION 

acters from one generation of organisms to another, as a 
process affected by means of the germ cells." All peculiar- 
ities or characteristics that are imparted to an individual 
through these germinal cells of the parents are spoken of as 
inherited. Any peculiarity that is imparted after conception 
has taken place is spoken of as acquired. If before birth, it 
is termed an intra-uterine acquisition; after birth, an extra- 
uterine acquisition. 

All inherited peculiarities are also said to be congenital, 
whether recognizable at birth or not. Likewise, all intra- 
uterine acquisitions are congenital; whereas extra-uterine 
acquirements are spoken of as extragenital. The careless 
use of the term congenital (many writers believing it to be 
synonymous with hereditary) has been the cause of much 
confusion. 

Concerning predispositions, Professor Orth, of Berlin, says : 
"Every incapacity of the body to resist the external causes 
of disease, every peculiarity of the constitution which renders 
the latter unable in the struggle of the body with the cause 
of disease to maintain the normal course of the vital phe- 
nomena, every such peculiarity of the constitution may be 
designated as a tendency, as a predisposition, to disease. 
All these predispositions to disease must be congenital and 
inherited, for they are a result of the phylogenetic develop- 
ment; they have their origin in the general characteristics 
inherent in the germ cells. This conception of what con- 
stitutes predisposition to disease does not contain anything 
mystical; it is not beyond the domain of science, and is just 
as capable of scientific treatment as any other pathogenetic 
question, though we must admit that our knowledge of the 
predispositions to disease does not go much beyond a few 
generalities." 



INTRINSIC FACTORS 55 

Heredity, therefore, is not as definite a factor as formerly, 
though we must continue to regard it as of great importance 
in the study of organic continuity. "Heredity repeats 
strength or weakness, good or ill, with like indifference." 
(Jordan and Kellogg.) Furthermore, one phase of this 
vast theme stands out very prominently, viz., all dental 
research relative thereto, and thus far conducted, is entirely 
inadequate. For this reason alone we should pause long 
before boldly denying its probable " influence" in the causa- 
tion of malocclusion of the teeth. Another very plausible 
reason why we should be less hasty in excluding the heredi- 
tary factors is, that many anomalies of other organs of the 
body (notably the eyes, e. g., errors of refraction, imbalance 
of the ocular muscles, etc.) are largely congenital and fre- 
quently transmitted from generation to generation. Surely, 
the teeth and jaws are not exempt from the "influences" 
which control such maldevelopments. 

"Our present plight seems to be exactly this, we cannot 
explain to any general satisfaction" all the causes of mal- 
occlusion of the teeth without the help of some hereditary 
factors; "and on the other hand, we cannot assume the 
actuality of any such factor in the light of our present 
knowledge of heredity." In view of this very unsettled 
state of our knowledge the author has, for some years 
past, preferred the terms intrinsic and extrinsic, instead of 
hereditary and acquired. 

INTRINSIC FACTORS 

Several anomalies of dentition, and sundry constitutional 
peculiarities, causing malocclusion of the teeth, are due to 
certain inherent, systemic influences. We term these the 



56 THE ETIOLOGY OP MALOCCLUSION 

intrinsic factors; some of them being congenital, and probably 
inherited, others not. 

Anomalies of Number. — These are found in both the tem- 
porary and permanent series, and frequently stand in causal 
relation to a malocclusion. Thus there may exist a deficiency 



Fig 




Congenital absence of the left upper temporary first molar, permitting the mesioversion 
of the second temporary and first permanent molars. 



in the number of teeth (Fig. 13) which permits the adjoining 
members to migrate into abnormal positions. When more 
than twenty teeth appear in the temporary dentition, or 
more than thirty-two in the permanent, we term it redun- 
dancy. This may lead to a crowded arrangement of them in 
their respective arches (Fig. 14). 



INTRINSIC FACTORS 



57 



According to Busch, 1 there are three kinds of super- 
numerary teeth: (a) Those with conical crowns and root; 
(b) tubercles; and (c) supplemental teeth, or those of normal 
form (Hollander). Premature extraction of a temporary 
tooth, or other traumatic influence, might occasionally be 

Fig. 14 




Shows the result of redundancy of number; note the supernumerary tooth between 
the upper centrals. 



responsible for a deficiency in the permanent set, but it 
is obvious that most anomalies of number are not due to 
extraneous causes. Atavism has long been regarded as a 
cause of redundancy; and more recently, their budding off 
from the common dental lamina has been suggested as a 
probable explanation of supernumerary teeth. But according 



» Deutsch. Monatsschr. f. Zahnheilk., 1886-87. 



58 THE ETIOLOGY OF MALOCCLUSION 

to Tomes, 1 "our present knowledge of the subject will not 
enable us to recognize the cause which has produced" 
anomalies in the number of teeth, though syphilis, rickets, 
and other maladies have frequently been mentioned. 

McQuillen, 2 Tomes, 3 and many other investigators have 
recorded numerous cases where anomalies of number were 
transmitted through several generations of the same family. 
Fig. 15 shows the. model of the upper arch of a father and 
Fig. 16 that of his daughter, taken from the author's collec- 
tion. Frequently the histories of such cases are so vitiated 
by premature loss of teeth, i. e., by caries and extraction, 
that they are of little value. Yet it is undoubtedly true 
that, in most cases, they are congenital and therefore 
transmissible. 

Anomalies of Form. — Though rarely met with, anomalies 
of form occasionally enter into a malocclusion, and they 
suggest interesting morphological questions. They may 
express themselves in various ways, e. g., deficiency, redun- 
dancy, dichotomes, etc. When affecting the anterior teeth 
they usually present a disfigurement, and frequently cause 
malocclusion of the adjoining teeth. Fig. 17 shows the 
models of a boy, aged nine years, exhibiting a fusion of the 
upper centrals and laterals. Fig. 18 illustrates a case of 
redundancy of form in a right upper central incisor, being 
fully one-third longer than the left central. Irregularity of 
size may also be complete, affecting the entire tooth, or 
partial, being limited to the crown or root. 

Abnormal Frenum Labium. — Occasionally, cases present 
themselves with an abnormal space (diastema) between 
the central incisors. 4 In the upper arch it is usually due to 



Dental Surgery, 5th ed. 2 Dental Cosmos. 

; Ibid. < Angle, Dental Cosmos, 1899. 



INTRINSIC FACTORS 



59 



an excessive development of the frenum of the lip. The 
fibers of this muscular attachment are of sufficient density, 



Fig. 15 




Shows model of a father with deficiency in size of the right upper lateral, and 
of number of the left lateral. 



Fig. 16 




From the upper arch of his daughter, exhibiting the same anomalies, though on the 
opposite side of the mouth. 



60 THE ETIOLOGY OP MALOCCLUSION 

and its movements so constant, that it prevents the teeth 
from coming into normal contact. 

Fig. 17 




Anomaly of form due to the fusion of tooth germs. 
Fig. 18 




Redundancy of form in a right upper central incisor. (After Lukens.) 



INTRINSIC FACTORS 61 

This factor is usually classified as an acquired cause, or as 
a "local" cause, but the author is fully convinced that this 
is an error. Clinical experience uniformly tends to show 
that in all cases brought under early observation the same 
abnormal conditions exist during the period of the temporary 
dentition. Wiedersheim 1 has shown that the raphe and 
papilla palatina are more highly developed in the embryo 
and during early infancy than in later life. This papilla has 
been investigated by Merkel, 2 who found it to be a sensory 
organ, and that it probably assists the palatine ridges in 
the trituration of food. Wiedersheim has also offered the 
suggestion that the raphe is "the remains of palatal teeth 
handed down even to man." 

In the absence of any authentic cases showing that an 
abnormal frenum is due to extraneous influences, we are 
constrained to regard it as an evidence of faulty develop- 
ment during embryonic life. Atavism suggests itself as a 
probable cause of such faulty development; but whatever 
the cause, it is plain that it is intrinsic. Fig. 19 shows the 
models of a case, aged eight years, in which the frenum of the 
upper lip was found to be the cause of the very wide space 
between the upper centrals. Ket chain's extended investiga- 
tions with the arrays conclusively demonstrate that such 
maldevelopments are in no wise related to an opening of the 
maxillary suture. 

Cleft Palate. — A congenital malformation of the palate 
usually so interferes with the development of the maxilla 
that if allowed to persist to the completion of the permanent 
dentition a malocclusion is an inevitable sequela. Fig. 20 
shows the models of a girl, aged fourteen years, in which 

1 The Struct ure of Man, p. 155, 

2 Ibid, p. 146. 



62 THE ETIOLOGY OF MALOCCLUSION 



Fig. 19 




Abnormal frenum labium. 
Fig. 20 



J :■ -ZG&StZ 


•x>\'M& 






L^BF J-- ^ 


- ■ # 11k ^1 




1 




^•'3j\i' "^^ jy ^H 







Upper arch of a case of malocclusion after an operation for cleft palate. 



INTRINSIC FACTORS 63 

this deformity and the accompanying malocclusion are very 
evident. Fortunately, such cases are rare, though, as 
Bland Sutton 1 long ago pointed out, they are transmissible. 
He says : " Cleft palate has been known to occur in offspring 
of affected members, and if it were possible to practise 
selective breeding in man as in dogs, a race of men with 
cleft palates and harelips could be produced." The treat- 
ment of the maxillary deformity usually falls to the oral 
surgeon, though subsequent orthodontic interference may 
occasionally be indicated. Dr. Dunn has reported the 
treatment of such a case to the American Society of 
Orthodontists (Denver, 1910). 

Anomalies of Position. — As already intimated, recent 
studies by orthodontists tend to emphasize the extraneous 
influences which are responsible for malocclusion. There 
remain a few forms of malposition, however, which cannot 
be attributed to them. I refer to transposition and those 
extreme forms of impaction for which Grevers 2 has suggested 
the term perversion. 

Fig. 21 shows the cast of a denture, sixteen years of age, 
in which the upper laterals, canines, and first bicuspids have 
exchanged places. Fig. 22 is from Dr. Cryer's collection, 
showing two impacted canines in the intermaxillary region. 
The causes of such anomalies are unknown, though obviously 
intrinsic. 

Asymmetry of the Jaws. — The jaws, or foundation structures 
upon which the teeth and their alveolar processes are placed, 
may, according to Talbot, be malformed in approximately 
30 per cent, of apparently normal individuals. It is clear 
that if these structures are inharmoniously developed to 

1 Evolution and Disease. 

2 IV International Dental Congress, St, Louis, 1904. 



64 



THE ETIOLOGY OF MALOCCLUSION 



any considerable degree, the superimposed teeth are very 
apt, upon closure, to come into malocclusion. Both the 



Fig. 21 




Transversion of the upper lateral incisors, canines, and first bicuspids. 
Fig. 22 




Perversion of the upper canines. (After Cryer.) 



INTRINSIC FACTORS 65 

upper and lower jaw may be thus affected, and while many 
arrests of development are traceable to abnormal occlusion, 
and therefore abnormal function (which speedily corrects 
itself after orthodontic treatment), there are rare instances 
which cannot be so easily disposed of. The causes of such 
developmental disturbances are not well understood. (See 
Chapter V.) 

Anomalies of the Tongue. — Congenital anomalies of the 
tongue, which have been described by Virchow, Holt, and 
others, exert their abnormal influences upon the dental 
arches, resulting in deformity. Schendel 1 and Angle 2 have 
reported cases of this kind. When the tongue is excessively 
developed (macroglossie) it tends to enlargement of the 
dental arches, causes a spreading of the teeth, and conse- 
quent loss of contact with their neighbors. When arrested 
development exists (microglossie) the full normal influence 
of its muscular action is absent, which is usually followed 
by a crowded arch. (Compare Fig. 28.) 

Nutritional and Specific Infectious Diseases. — Diseases of 
nutrition, like rachitis, scorbutus, and marasmus, generally 
affect the process of dentition, though they are usually con- 
fined to the period of infancy. Congenital syphilis very 
often affects the permanent teeth, and, according to 
Hutchinson, "typical syphilitic teeth have notches in their 
incisal edges and are dwarfed both as regards their length 
and breadth." According to Keyes, Black, and others, such 
teeth are not invariably an evidence of this disease. It has 
also been claimed by Hill, 3 Saleeby, 4 and other English 



1 Deutsch. Monatssch. f. Zahnheilk., 1903. 

2 Malocclusion of the Teeth, 7th ed., 1907. 

3 Heredity and Selection in Sociology, London, 1907. 

4 Parenthood and Race Culture, New York, 1909. 



66 THE ETIOLOGY OF MALOCCLUSION 

writers that racial poisons, like alcohol and lead, are capable 
of producing malformations. And the late Herbert Spencer 1 
suggested the deleterious influence of vaccination as a prob- 
able cause of the alarming increase in teeth and eye affections 
among the inhabitants of Great Britain. 



EXTRINSIC FACTORS 

The factors embraced in this group are more readily 
recognized, probably because the operator comes in daily 
contact with them. A thorough knowledge of them is also 
imperative, since it enables one to successfully combat their 
action and thus obviate the development of many forms 
of malocclusion. 

Premature Loss of Temporary Teeth. — The necessity for 
the conservation of the temporary teeth during their allotted 
period is a truth that is gaining wide acceptance. The 
cumulative evidence of the disastrous results following their 
early loss through promiscuous extraction, or neglected 
progressive caries, is becoming a sufficient argument to 
all conscientious practitioners. Premature loss and pulp 
exposure due to neglected caries tend seriously to interfere 
with normal function; and in the development of the denture 
and its related structures normal function plays, the leading 
role. Furthermore, the loss of a single tooth, or even of a 
part of a tooth, produces a break in the continuity of the 
arch and permits abnormal movements of the adjacent teeth. 

Premature Loss of Permanent Teeth. — The early loss of 
permanent teeth, especially of the first molars, is now 

1 Facts and Comments. 



EXTRINSIC FACTORS 67 

regarded as an established etiological factor of malocclusion. 
In action it is similar to the loss of temporarry teeth as 
described above, and is very frequently accompanied by 
a deepening of the "bite/' or a destruction of the normal 
plane of occlusion. 

Prolonged Retention of Temporary Teeth. — The prolonged 
retention of temporary teeth, should they persist long 
after the need which occasioned them has ceased, is another 
prolific factor in the causation of malocclusion. An erupt- 
ing tooth is suspended, as it were, by its soft attachment 
tissues, and the slightest pressure, if it be constant, is 
sufficient to deflect it in its course. The orifice through 
which a tooth passes in its journey of eruption is greatly 
enlarged by the absorption of the crypt walls. Of course, 
we have our eruption tables, but many teeth deviate from 
the averages there set forth; and clinical observation teaches 
us that there is an opportune time for the exfoliation of 
each temporary tooth. The operator should, therefore, 
exercise judgment in every case of removal of temporary 
teeth. Fig. 23, a, shows the evil results of the premature 
loss of temporary molars, permitting the mesial eruption of 
the upper first molar. Subsequently, the first and second 
bicuspids were also forced into mesioversion, and thus 
encroached upon the space the cuspid should occupy, which 
came at a still later period. The left upper temporary 
lateral was retained too long, causing a linguoversion of its 
permanent successor (6) . On the right side (c) the elongated 
first molar is noted coming in contact with the lower gingival 
ridge, which is due to the early loss of the lower first perma- 
nent molar. 

Nasal Obstruction. — The importance of normal respira- 
tion and of a rational nasal hygiene, particularly during 



68 



THE ETIOLOGY OF MALOCCLUSION 



Fig. 23 




a, mesioversion of the upper permanent molar resulting from premature loss of 
temporary molars; b, linguoversion of the upper lateral due to prolonged retention of 
its predecessor; c, beginning supraversion of an upper molar which has been deprived 
of occlusal contact. 



EXTRINSIC FACTORS 69 

the developmental period, can hardly be overestimated. 
"Obstruction of the free passage of air through the nose 
is one of the most frequent and important consequences of 
nasal disease. The obstruction may be partial or complete, 
periodical or constant. When chronic nasal obstruction 
occurs at an early age, it exercises deleterious effects on the 
neighboring parts, on the general well-being, and on the 
development and growth of the whole body. The full 
consequences of nasal obstruction are most frequently seen 
in children suffering from adenoids." It may be due 
to one or • more of the following anomalous conditions: 
(a) Adenoids, (b) deformities of the septum, (c) hyper- 
trophies of the turbinates, and (d) nasal polypus. Another 
condition frequently met with, and very often associated 
with lymphoid hyperplasia of the nasopharynx, is hyper- 
trophy of the tonsils, constituting an hypertrophy which 
includes what has been called the "lymphoid ring," or 
"ring of Waldeyer." 

The more important direct effects of nasal obstruction 
Lack 1 places as follows: Loss of nasal function, the open 
mouth and its mechanical consequences, deficient oxygenation 
of the blood, and deformity of the chest walls. The symptoms 
due to a constantly open mouth, and which especially 
appeal to the orthodontist, he enumerates thus: The typical 
fades, malformation of the jaws, malposition of the teeth, 
and collapse of the alee nasi. 

In Figs. 24 and 25 are shown the models and photographs 
of a girl, aged twelve years, which are typical of the conditions 
under discussion. In his very able investigation of this type 
of deformity Lack concludes as follows : 

1 Diseases of the Nose, p. 56. 



70 THE ETIOLOGY OF MALOCCLUSION 

Fig. 24 




Malocclusion resulting from nasal obstruction. 
Fig. 25 




Facial deformity accompanying case shown in Fig. 24. 



EXTRINSIC FACTORS 71 

"Thus most observers agree that the deformities in 
question are frequently, if not invariably, associated with 
mouth breathing. Ziem's experiments demonstrate con- 
clusively that they may result from it. He obstructed the 
nostrils of puppies and other young animals, and found that 
great deformity of the bones of the face resulted in later 
life. There seems every reason to believe that nasal obstruc- 
tion precedes and causes the facial deformity. The latter 
is never congenital, but it follows after years of mouth 
breathing; the changes can be arrested, and will even retro- 
gress, if the cause be removed." 

Vertical and mesial malrelations of the lower dental arch, 
and malformation of the mandible, are frequently associated 
with mouth breathing. Case 1 suggested the latter as a cause, 
and that hypertrophy of the tonsils frequently stands in 
causal relation to them. 

But the subject of nasal obstruction is a vast one, forming 
a large part of the field of rhinology, and it would carry us 
far beyond the confines of the present chapter to attempt a 
detailed treatment of it. For further study, the student is 
referred to text-books on diseases of the nose and throat. 

Habits. — Another rather fruitful cause of malocclusion are 
sundry habits of childhood. Foremost among these may be 
mentioned the habits of thumb and tongue sucking, and 
that of lip biting. The first is probably the most common, 
and very frequently hardest to discontinue. They are 
usually acquired during infancy, when the parents or nurse 
regard them as harmless, or even pleasing. But when we 
reflect on the mechanics of maxillary development, on the 
ease with which growing tissues are moulded into form, and 

i Dental Review, July, 1894. 





Fia. 26 






■^ ^^^^F?<w-s*^ 






] 


vF vv> v- 








3 ' H» H% w 




, 




fc^^ 
















Lip biting. 



EXTRINSIC FACTORS 73 

on the constancy of these subtle influences, we readily appre- 
ciate their gravity and source of harm when continued for a 
long period. Fig. 26 shows the influence of thumb sucking, 
causing the labioversion of the uppei r incisors and the lingual 
inclination of the lower. The constant biting and sucking 

Fig. 28 




Tongue sucking. 

of the lower lip causes similar deformity, as shown in Fig. 27. 
Tongue sucking, though less common, permits the elonga- 
tion of the posterior teeth (allowing an abnormal elevation 
of their occlusal planes) and prevents the normal contact of 
the anterior teeth. Fig. 28 shows a case of this type. 

Some writers have classified mouth breathing as a habit, 



74 THE ETIOLOGY OF MALOCCLUSION 

though it is obvious that it is but a symptom of pathological 
conditions of the respiratory tract. Herbst 1 also mentions 
the probable influence of the following, which are frequently 
overlooked : The use of pacifiers during infancy, the sucking 
of cheeks, the biting of the upper lip in mesioclusion of the 
lower arch, resting the cheeks upon the hands, resting the 
chin upon the hand, and sleeping on one side. According to 
this author, Peckert has suggested the biting of cigar tips 
as practised by cigarmakers; Palltorf the biting of threads 
among seamstresses; the playing of musical instruments 
like the flute, etc., and the artificial deformities of the teeth 
as practised by many primitive races (Schroder), as causing 
deformities of secondary importance. 

Accidents and Traumatic Influences. — Falls, or violent 
blows upon the teeth, and fractures of the alveolar processes 
and maxillae, may cause malocclusion if their treatment is 
neglected; though Angle and other writers have conclusively 
shown that such deformity can readily be prevented if the 
proper treatment is provided. Tomes 2 reports a case of 
malocclusion accompanied by malformation of the mandible, 
in a patient, aged twenty-one years, which was due to a 
burn about the neck and chest at the age of five. Fig. 29, 
taken from the author's collection, shows the casts of a 
youth, aged eighteen years, who was kicked in the mouth 
by a mule during his eighth year. 

Dr. Chilcott, 3 of Bangor, Me., presents a paper in which 
he describes an "Obstetrical Deformity of the Mandible," 
which he attributes to a breech presentation. It is claimed 
that such presentations may cause a straightening of the 



1 Zahnarztl. Orthopadie, p. 84. 

2 Dental Surgery, 5th ed. p. 166. 

3 Dental Cosmos, March, 1906. 



EXTRINSIC FACTORS 



75 



mandible, resulting in mesioclusion of the lower arch and 
malformation of the mandible. 



Fig. 29 




Malocclusion due to an accident. 

Pericemental Affections. — It is well known that chronic 
infections of the pericementum and alveolar processes, 
commonly termed pyorrhea alveolaris, or alveolitis, may 
cause malposition of the teeth. Fig. 30 shows the cast of a 
denture, thirty-eight years old, in which the upper incisors 
were the seat of such infection, and which had gradually 
caused their labial movements during a period of two years. 
The distoclusion of the lower arch (which is evident) must 
not, however, be attributed to this cause, but to nasal 



76 



THE ETIOLOGY OF MALOCCLUSION 



obstruction in childhood, which the history of the case 
clearly established. 





Fig. 


30 














^^^s 


■ ;' ~M 


mm 




w 

1 


- _■•"-*'. 1 




1 




Mbp**. 





Malalignment due to alveolitis. 
Fig. 31 



28(810085*!' 


^^^^^^^^ 






raK? .'% '"'"'/*'' 








m ' -jgJW 


/// 






1 . flf . 


- MIB ^ ^ 


'.*■- 


■ 






fc2> 


I 

M 


I^^^^fl 









Hyperplastic formation of connective tissue preventing the eruption of a 
lower bicuspid. 

Neglected progressive caries of the deciduous teeth usually 
leads to pulp exposure and infection, and to chronic abscesses 



UNKNOWN FACTORS 77 

discharging in a sinus. At the meeting of the Missouri 
State Dental Association for 1906, the author reported a 
case of a youth, aged sixteen years, who suffered from such 
neglect during his eighth year. The point of infection was 
in the left lower deciduous first molar, and caries soon 
destroyed all of the remaining tooth tissue that was not 
resorbed. The membranous surfaces of the adjacent tissue 
being inflamed, together with a cessation of suppuration, 
so coalesced as to result in a fibrous adhesion. This hyper- 
plastic formation of connective tissue caused the impaction 
of the first bicuspid, completely preventing its eruption 
(Fig. 31). 

Disuse and Artificial Nursing. — Disuse of the dental organs 
during childhood or the developmental period, and the 
artificial nursing of infants, are frequently mentioned as 
causes of arrested development of the maxilla? and their 
processes. The modern methods of cooking food and 
neglected caries are also said to be largely responsible for 
the prevalent practice of improper mastication. 

In his study on The Mechanical Formation of the Denture, 
Korbitz 1 has carefully analyzed such influences as active 
muscular pressure; the passive pressure of the soft parts; 
atmospheric pressure; pressure of the adhering tongue, as 
noted by Cryer; the functional influence of occlusion, etc., 
all of which are minimized, or even perverted, in cases 
where the above-mentioned factors are operative. 

UNKNOWN FACTORS 

The author has tried to enumerate all of the accepted 
factors of causation, yet he realizes that the facts here 

i Qegt f -Ungar. Vierteljahrsch. f. Zahnheilk., 1906. 



78 THE ETIOLOGY OF MALOCCLUSION 

presented form but the merest outline of this subject. The 
problems of causation represent a field so vast that its 
boundary lines are hardly discernible. Many of the truths 
therein enclosed are reserved for future investigation. Some 
of the causes already mentioned, and others less generally 
accepted, might quite advantageously be grouped into a 
class and labeled as unknown. 

Some authors contend that civilization is a cause, that 
our modes of life in contrast with primitive man make for 
retrogression and degeneration. But there is little in the 
way of direct evidence regarding this, and it is probably 
only "one of those delightfully vague suggestions which 
are thoughtlessly advanced/' 1 Wallace very significantly 
adds: "Knowing, as we do, that 'thousands' of Chinese 
skulls have been examined, and only one trivial case of 
irregularity has been observed, and knowing also that the 
Chinese belong to the most ancient civilization extant, and, 
further, having been taught that irregularities are frequent 
among Hawaiians, we must be careful about laying too much 
credence on the idea that civilization is anything more than 
a frequent concomitant of irregularities." 

Race mixture has been suggested as a cause, especially in 
America, which has very aptly been called "The Melting 
Pot." It has been claimed that in mixed types, "the product 
of a cross between a broad- and a long-headed race, one 
contributes the head form, while the other the facial pro- 
portions." Anthropologists have frequently reported dis- 
harmonisms of this kind, but the data upon which similar 
deductions regarding the teeth are based are very scanty. 

In conclusion, it may be worth emphasizing the one great 

1 Wallace, Irregularities of the Teeth, p. 98. 



UNKNOWN FACTORS 79 

difficulty confronting investigations of this kind, viz., the 
lifetime of an observer is too brief to comprehend more than 
three generations; and even in cases where this is possible the 
data are frequently so vitiated that they are of little value. 
Our greatest hope for the future, therefore, must lie in the 
realm of experiments on the lower animals. 



CHAPTER V 

THE DIAGNOSIS OF MALOCCLUSION 

FIRST PRINCIPLES 

The dental axiom that only a normal denture can perform 
normal functions is gaining wide acceptance. This not only 
implies immunity to caries and the absence of sundry lesions 
of the oral tissues, but a denture whose architectonic form 
approaches the ideal. To perform the complex functions in 
response to which the teeth were brought into being, they 
develop characteristic forms and assume very appropriate 
anatomical positions. An intimate knowledge of these fine 
symmetrical relations is very essential in orthopedic practice, 
for in the correction of every malocclusion we are confronted 
with the two queries: 

(a) What is the nature and extent of the abnormality to 
be corrected? 

(6) What is the condition we wish to establish? 

Ultimately, these inquiries always lead us to ask the 
further questions : 

(c) What movements will be necessary? 

(d) What method of treatment will best accomplish these 
movements? 

To the beginner the selection of the remedy, or the answer 
to question (d), seems most important; but it requires very 
little experience to show that this is an error, and that the 
only logical approach to the problems is in the order in 
which they are here presented. 



FIRST PRINCIPLES 



81 



The answer to the first query (a) implies an accurate 
diagnosis, an interpretation of the abnormality on a basis 
of normality; and since the aim of every treatment is the 
establishment of normal relations, the significance of what 
constitutes a normal denture becomes evident. 

The arrangement of the teeth in the form of two parabolic 
curves within the alveolar processes of the jaws is called their 
alignment. When a tooth deviates in its position from this 

Fig. 32 





Alignment and malalignment. 

ideal line, it is said to be in malalignment, or malposition 
(Fig. 32). When brought together in the act of mastication, 
normally arranged teeth are found to interdigitate very 
accurately. This intimate relationship existing between the 
cusps of the lower teeth in normal contact with those of the 
upper is termed occlusion. It is a primal function of the 
teeth, and is dependent upon their position. When a tooth 
occupies an abnormal position, and hence, on closure, comes 
into abnormal contact with its antagonists, it is said to be 
6 



82 



THE DIAGNOSIS OF MALOCCLUSION 



in malocclusion (Fig. 33). The latter is a generic term used 
to collectively designate the various abnormal forms of 
occlusion. Occasionally, teeth assume such extreme mal- 
positions that they are actually in non-occlusion, failing in 
contact with their antagonists (Fig. 28). 

Malocclusion of the teeth presents itself in an almost end- 
less variety of forms, and for many years it was an accepted 
belief that their classification constituted a hopeless task. 
Fortunately, numerous investigators were not similarly 

Fig. 33 




Occlusion and malocclusion. 

minded, but endeavored to bring order into this apparent 
confusion, to detect similarity in so vast a number of devia- 
tions from normality. They realized that a comprehensive 
classification constituted the main problem in the difficult 
art of diagnosis, and hence devised systems for this purpose. 
The first recorded attempt was by the German dentist, 
Kneisel, 1 who proposed the two groups, partial and complete. 



Der Schiefstand der Zabne, Berlin, 1836. 



DEFINITION 83 

By the term partial, he ment malposition of the individual 
teeth; and by complete, he had reference to the abnormal 
relations of the dental arches. From among the many 
other methods proposed since then, we may mention those 
by the following authors as the most important: Carabelli, 1 
Magitot, 2 Iszlai, 3 Sternfled, 4 Angle, 5 Welcker, 6 Grevers, 7 
Herbst, 8 Zsigmondy, 9 and Villain. 10 

Most of these efforts at conceptual shorthand are more 
or less comprehensive, and are largely based upon patho- 
logical manifestations. Many others proposed from time 
to time were based upon the treatment to be instituted, and 
were, needless to state, fallacious. Furthermore, several 
of these schemes contained proposals for an improvement 
in our nomenclature, embracing systems of terms which, 
by their very etymology, would convey a picture of the 
conditions implied. But desirable as such efforts appear, 
they have not altogether removed our difficulties, and, at 
the present writing, not one of them has gained universal 
acceptance. 

DEFINITION 

Broadly interpreted, every diagnosis implies a considera- 
tion of several general conditions, e. g., the age, general and 
oral health of the individual, the relative degree of growth 
and development, the recognition of causative factors, etc. 

1 Handbuch der Zahnhl., Wien, 1844. 

2 Traite des anomalies du systeme. 

3 Internat. Med. Cong., London, 1881. 

4 Ueber Biszerten und Bisanamolien, Miinchen, 1888. 
s Dental Cosmos, 1899. 

6 Archiv f. Anthropologic, 1902. 
■ IV Internat. Dental Cong., St. Louis, 190-4. 
s Deutsch, Zahnarztl. Woch., 1904. 
9 Oestr. Zeit. f. Stomatologic, Wien, 1905. 
'o Zeit. f. Zahnarztl. Orthopadie, Berlin, 1910. 



84 THE DIAGNOSIS OF MALOCCLUSION 

Custom, however, limits the use of the term to the art of 
differentiating one affection from a group of abnormalities 
having similar symptoms. Thus in orthodontic practice it 
embraces: (a) The distinguishing of one form of mal- 
occlusion from another; (b) the detection of anomalies of 
dentition (and of the jaws and related structures) other than 
those of position and occlusion; and (c) the degree of facial 
deformity associated therewith. 

GENERAL OUTLINE OF THE ANOMALIES OF 
DENTITION 

In 1877 the French dentist Magitot 1 proposed a com- 
prehensive scheme for the many deviations from normality 
found in the denture of man. Though based upon the 
records of 2000 cases, it was formulated prior to the introduc- 
tion of many of our present methods of treatment, which 
latter have greatly extended the field of dental orthopedics. 
He therefore omitted mention of the deformities of the 
facial lines, and of the maxillary structures beyond the 
teeth, presenting a classification substantially as follows: 
(a) Anomalies of eruption; (b) anomalies of number; (c) 
anomalies of form and structure; and (d) anomalies of 
position. 

The anomalies of eruption may be further classified into 
premature and tardy; those of number, into deficiency and 
redundancy; those of form and structure, into partial and 
complete, etc. Orthodontic art occupies itself largely with 
the correction of what Magitot termed the anomalies of 
position, but it should not be forgotten that any of the other 
forms mentioned above (and anomalies of the jaws) may be 
found associated with them. 

1 Traite des anomalies du systeme. 



THE DIFFERENTIATION OF THE VARIOUS FORMS 85 



THE DIFFERENTIATION OF THE VARIOUS FORMS 

Let us first ask ourselves, What conditions usually enter 
into a malocclusion? The answer to this question must be 
stated as follows: There are just three conditions which 
may conjoin in a malocclusion — conditions so fundamental 
that most writers now recognize their basic significance — 
and each one of these conditions is reducible into element- 
ary divisions, regardless of their manifold combinations. 
Concisely expressed, these three conditions are: (1) Mal- 
formation of the jaws and their processes; (2) malrelation of 
the dental arches; and (3) malposition of the teeth. Let us 
briefly consider these three conditions in the order of their 
gravity. 

Malformation of the jaws is the most serious condition 
we have to deal with, and at times constitutes a deformity 
so severe that its correction lies outside of our domain. 
Therefore, when a case presents a pronounced malformation 
of one or both jaws, it should be emphasized and receive first 
mention in the naming of the deformity (Fig. 34). 

If we could remove all of the soft, overlying tissues from 
the mandible in such a case, exposing it to full view, there 
can be no doubt that the general deformity of this bone, and 
not the superimposed teeth and their occlusion, would attract 
our first attention (Fig. 35). And as we ponder over it, how 
futile all orthodontic efforts at correction would seem, 
especially if they blindly ignored this foundation. Of course, 
the age of the patient is an important factor in the treatment 
of these cases; and recent developments in the methodology 
of our art have established the fact that early treatment 
of malocclusion (by securing normal dental function), 



Fig. 34 




Mandibular macrognathism. 
Fig. 35 




Shows the malocclusion of Fig. 34. The bilateral mesioclusion is but a 
symptom of the jaw deformity. 



THE DIFFERENTIATION OF THE VARIOUS FORMS 87 

invariably corrects the menacing deformity beyond the 
teeth and their alveoli. 

It is obvious, moreover, that malformations of the jaws 
may express themselves in several ways, hence it is desirable 
to enumerate the various kinds and to adopt a satisfactory 
terminology. Now, medical literature has for years recog- 
nized the congenital deformities of the jaw T s under the 
group-term polygnathism, embracing epignathism, agnathism, 
hypognathism, etc. And continental European writers have 
used the ending gnathia (meaning jaw) quite liberally, so 
that it is not entirely new in dental science. The author, 
therefore, suggests its adoption in this connection. 

Deformities of the jaws may unfold themselves as over- 
developments, for which the term macrognathism serves 
admirably; or they may express themselves in arrested 
development, in which case it is termed micrognathism. 
When confined to the upper jaw, it may be indicated by the 
word maxillary; or, if confined to the lower, it is termed 
mandibular. When both jaws are similarly affected, the 
term bimaxillary is used. Furthermore, the author is of 
the opinion that these terms should only be used for those 
extreme deformities which are not amenable to orthodontic 
procedure. 

The arrangement of the teeth in the form of two arcades 
or graceful curves (an upper and lower, each with its right 
and left sides) demands a fine adjustment of the individual 
members of each if a symmetrical, well-balanced ensemble 
is to be established. Bearing in mind that w T e are here 
dealing wdth bilateral symmetry, w T e can readily see how all 
of the upper teeth, or all of the low T er, could be in perfect 
alignment in their respective arches, and yet, on closure, 
fail to come into normal occlusion. In other words, either 



88 THE DIAGNOSIS OF MALOCCLUSION 

arch (even though it retain a normal form) may be so 
displaced upon its osseous base that normal contact with 
antagonists becomes impossible. We term this condition 
arch malrelation (Fig. 36). It is obvious that this is invari- 
ably accompanied by malposition of the teeth, though the 
latter frequently exists without the former. Differently 
expressed, in cases of simple malposition, accompanied by 
normal relation of the arches, we have to deal only with 
anomalies of arch form. 

Since the publication of KneisePs book many writers have 
recognized a few of the various forms of arch malrelation, 
but it remained for Angle to emphasize their far-reaching 
significance and to discover the unilateral and bilateral 
deviations. He also proposed diagnostic points, by means 
of which the mesial and distal variations may easily be 
detected. The mesiodistal relationship, or occlusion, of the 
first permanent molars is thus made to serve as an aid in 
the diagnosis of the mesial and distal forms. Of course, in 
mutilated cases allowance must be made for the possible 
abnormal position of these teeth. 

Angle's Classification. — Of all the schemes alluded to 
above, the Angle classification is the most widely accepted. 
It proposes a division of all forms of malocclusion into three 
classes as follows: 

Class I. Normal mesiodistal relation of the arches. 

Class II. Distal relation of the lower arch. 

Class III. Mesial relation of the lower arch. 

In its essence, therefore, it is a classification based upon 
the relations of the two dental arches (an exceedingly impor- 
tant distinction), though its numerical terminology does 
not indicate this. 

Now, in a consideration of arch relation we base our 



THE DIFFERENTIATION OF THE VARIOUS FORMS 89 

differentiation upon normal closure, or occlusion, hence 
the ending elusion may readily serve us in our terminology 
for designating the various forms. To this ending we 

Fig. 36 





B 



Normal and abnormal arch relation. A is diagrammatic of their normal relation, as 
indicated by the plane a, b, c, and d; in B their relation in a bilateral mesioclusion is set 
forth, the perpendicular b x indicating the normal. The line b y suggests their relation 
in distoclusion. 



prefix well-known anatomical terms, and thus get the fol- 
lowing: Mesioclusion, when the lower arch is mesial in 
its relation to the upper (Fig. 36); distoclusion, when it is 



90 



THE DIAGNOSIS OF MALOCCLUSION 



distal to normal (Fig. 37). As stated above, both sides of 
an arch may be affected, when it is termed a bilateral 



Fig. 37 




Bilateral distoelusion complicated by linguoversion of the upper central ii 



THE DIFFERENTIATION OF THE VARIOUS FORMS 91 

mesioclusion or distoclusion. Or, if only one side is involved, 

we term it a unilateral mesioclusion or distoclusion (Fig. 38). 

Fig. 38 




Unilateral distoclusion. 



92 THE DIAGNOSIS OF MALOCCLUSION 

In a consideration of 1000 cases of malocclusion, Angle 
found 692 in which the mesiodistal relations of the arches 
were normal, the main difficulty being a malposition of the 
individual teeth, or an anomaly of arch form. In other 
words, one or more teeth were in malalignment, hence mal- 
occlusion, a condition recognized by all writers and loosely 
termed "irregularities." That there were several kinds of 
malposition was generally known, but again it remained for 
Angle to enumerate seven primary forms, and to call special 
attention to their possible combinations. Unhappily, this 
writer has become so enamored of the word occlusion that 
he makes it serve in this instance by prefixing anatomical 
terms to it for the designation of these seven deviations. 
The author firmly believes that it would be a distinct 
advance if an ending denoting position were used instead, 
because the spoken w T ord should be measurably descriptive. 

Again, having adopted the ending elusion as appropriate 
for the designation of malrelation of the arches, it becomes 
necessary to use another term to denote malposition of the 
individual teeth. Hence the author suggests that the widely 
used medical ending version (Lat. vertere, to turn, to change 
position) be used to denote malposition of individual teeth. 
This gives the following terms: Labioversion or buccoversion 
to denote labial or buccal malposition; linguoversion, when 
a tooth is lingual to normal; mesioversion, when mesial to 
normal; distoversion, when distal to normal; torsoversion, 
when rotated on its axis; supraversion, to denote elongation; 
infraversion, for depression (Fig. 28) ; perversion, for impacted 
teeth (Fig. 22); and transversion, for transpositions (Fig. 21). 

Now, the mere fact that approximately 70 per cent, of all 
forms of malocclusion exhibit neither extreme malformation 



THE DIFFERENTIATION OF THE VARIOUS FORMS 93 

of the jaws nor mesial or distal malrelation of the arches, 
emphasizes the advantage of a separate term for this large 



Fig. 39 




Typical neutroclusion. 



94 THE DIAGNOSIS OF MALOCCLUSION 

class (Class I, Angle). The author/ therefore, suggested 
that the word neutroclusion (Lat. neutro, in neither direction; 

Fig. 40 




Neutroclusion complicated by extreme labioversion of the upper incisors. 
1 Dental Cosmos, April, 1911. 



THE DIFFERENTIATION OF THE VARIOUS FORMS 95 



occlusio, to close) be used for the naming of this group 
(Fig. 39). 



Fig. 41 




A, bilateral distoclusion complicated by extreme labioversion of the upper incisors; 
B, bilateral distoclusion complicated by infraversion of the upper incisors. 



96 THE DIAGNOSIS OF MALOCCLUSION 



SUMMARY 

In confirming the diagnosis of a malocclusion we proceed 
by excluding all possible conditions in the order of their 
gravity. Thus dentofacial deformity, which is always 
serious, is first considered. Owing to the fact that it com- 
prises a large field and involves many grave points, it was 
deemed best to treat it separately (Chapter VI). Next in 
importance comes a consideration of malformation of the 
jaws; then the relation of the arches, or the totality of their 
alignment and occlusion; then the occlusion and alignment 
of each tooth, which necessarily implies the form of each 
arch; and such other anomalies as may be present. 

Finally, the naming of these deformities should be governed 
by the following rules : 

1. Jaw deformities so extreme as to be beyond the scope 
of orthodontic treatment should receive first consideration. 
Their accompanying malocclusions are merely symptoms. 

2. Arch malrelations amenable to orthodontic treatment 
are next in importance. 

3. All cases of malocclusion accompanied by a neutral 
relation of the arches are spoken of as neutroclusions. 

4. The individual peculiarities of any given case are best 
expressed by adding such qualifying phrases as "compli- 
cated by labioversion of the upper incisors," or " infr aversion 
of the upper incisors," etc. (Figs. 40 and 41). 



CHAPTER VI 

FACIAL DEFORMITIES DUE TO MALOCCLUSION 
NORMAL VARIATIONS OF THE HEAD FORM 

As intimated in Chapter I, a frequent attribute of mal- 
occlusion is a marked inharmony of the facial lines. A 
rational basis for conclusive deductions regarding these 
deformities is a knowledge of the normal variations of 
facial form. To a large extent all faces are similarly formed, 
and their likenesses are patent to everyone; yet there exist 
in every face certain lineaments of character which stamp 
it with individuality. Indeed, in probably no other part 
of the human form is the variability of features so evident. 

The normal variations of organic beings have long been 
a subject for careful study; and since Darwin's day with 
renewed earnestness. It remained for Blumenbach, 1 Cam- 
per, 2 and Prichard 3 to first draw attention to the relationship 
existing between the teeth and their osseous base and the 
profile or facial lines of man. This phase of scientific inquiry 
now forms an important division in anthropology, where, in 
common with other elaborate systems and classifications, it 
is termed anthropometry, the science of human measure- 
ments. The comparative study of the variable morpho- 
logical aspects of the skull comprises a subdivision termed 
craniometry. When the measurements are made upon the 

i Gottingen, 1775. 2 Berlin, 1792. 3 London, 1836. 

7 



98 FACIAL DEFORMITIES DUE TO MALOCCLUSION 

Fig. 42 Fig. 43 




Fig. 44 




Top view of skulls: Fig. 42, negro, index 70, dolichocephalic, Fig. 43, European, index 
80, mesocephalic; Fig. 44, Samoyed, index 85, brachycephalic. (After Tyler.) 



NORMAL VARIATIONS OF THE HEAD FORM 99 

living head it is termed cephalometry. Numerous methods 
for measuring the features have been devised, though very 
few have been sufficiently standardized to win universal 
acceptance. Much of the development of this branch of 
science we owe to the French anthropologist Broca. 

Cephalic Index. — In comparing a number of skulls even 
the beginner experiences little difficulty in detecting differ- 
ences of shape. "The form of the head is for all racial pur- 
poses best measured by what is technically known as the 
cephalic index. This is simply the breadth of the head above 
the ears expressed in percentage of its length from forehead 
to back. Assuming that this breadth is 100, the width is 
expressed as a fraction of it. As the head becomes pro- 
portionately broader — that is, more fully rounded, viewed 
from the top down — this cephalic index increases. When 
it rises above 80, the head is called br achy cephalic; when 
it falls below 75, the term dolichocephalic is applied to it. 
Indexes between 75 and 80 are characterized as meso- 
cephalic. ,,1 Figs. 42, 43, and 44 are diagrammatic of these 
variations of form. 

Other Systems of Measurement.- — Among the other systems 
proposed for the determination of differences of shape, 
mention may be made of Camper's method for the measure- 
ment of the facial angle (Figs. 45 and 46), Flower's gnathic 
index, and Turner's dental index. 2 By means of the gnathic 
index, which is used to determine the amount of projection 
of the lower part of the face, the races of mankind may be 
divided into three groups, as follows: Orthognathous, when 
below 98; mesognathous , when 98.1 to 103; prognathous, 



i Ripley, The Races of Europe, New York, 1899. 
2 Tomes, Dental Anatomy, 5th ed., p. 517. 



Fio. 45 




Fig. 46 




Camper's measurements of the facial angle. 



NORMAL VARIATIONS OF THE HEAD FORM 101 

when above 103. With the dental index we determine "the 
relation of the size of the teeth to that of the skull," and 
get the three groups termed microdont, index 42; mesodont, 
index 43; and megadont, index 44 and above. 



Fig. 47 




Normal variation of the symphysian angle. 
Fig. 48 



B 




Noimal variation of the symphysian angle. 



Fig. 49 




Normal variation of the symphysian angle. 
Fig. 50 





Normal variations of alignment of the upper teeth. (After Broca.) 




Fig 51 




Fig. 52 




Showing variations in the relative position of the lower third molar. 



104 FACIAL DEFORMITIES DUE TO MALOCCLUSION 

Still other differences of interest are the anthropological 
varieties of the palate, termed by Turner dolichuranic, 
mesuranic, and brachyuranic; and the variations due to 
the development of the muscles of mastication. The latter 
are readily recognized in the changeable position of the 



Pig. 54 



Fig. 55 




jB 




H 




§p V, : '" 


^*^*K 1 


W ->^. -? 


"N«v ::•■-' ,^««»^» WI ^. ~ ; &%j>^| 






PSSb 




'iaiJHK * 


mmmmJA 



Normal variation of the profile 
taken from life. 



Dental model of the case shown in Fig. 54. 



temporal ridge; the differences in width of the ascending 
rami of Europeans when compared with the aborigines; the 
varying degrees of parallelism of the borders of the rami; and 
the outward and inward everted angles of the lower jaw, 
which affect the width of the lower part of the face. Other 
and even more important facts of interest are the normal 



NORMAL VARIATIONS OF THE HEAD FORM 105 

variations of the symphysian angle (Figs. 47, 48, and 49), 
and the ethnological deviations observed by Broca in the 
forms of the dental arches. Of the latter there are four 
varieties, which he designated parabolic, hyperbolic, ellip- 
tical, and U-shaped (Fig. 50). 



Fig. 56 



Fig. 57 





Normal variation of the 
profile taken from life. 



Dental model of the case shown in Fig. 56. 



N( 



A still further evidence of variability is to be found in 
the relative position of the lower third molars. Thus in the 
aborigines it usually is in front of the anterior border of the 
coronoid process, while in the Europeans it may be partly, 
or entirely, hidden (Figs. 51, 52, and 53). The teeth and 



106 FACIAL DEFORMITIES DUE TO MALOCCLUSION 

bones, as well as the accessory sinuses of the nose, differ 
also in their size and form. 

Summary. — In his measurements of the facial lines, Camper 
discovered that in an Australian black they approached an 
angle of 85 degrees; in a European, 95 degrees; and in the 
beautiful forms of Greek art, 100 degrees or more. This 



Fig. 58 



Fig. 59 




Normal variation of the 
profile taken from life. 



Dental model of the case shown in Fig. 58. 



variation is largely due to the backward sloping of the 
symphysis, which in the lower races approaches the chinless 
form of the anthropoid ape. The degree of prognathism, or 
position of the denture in its relation to the skull as a whole, 
must also be taken into consideration. These osseous varia- 
tions affect all skulls in varying degree, and in Figs. 54, 56, 



NORMAL VARIATIONS OF THE HEAD FORM 107 

and 58 we see three photographs which, though unlike in 
general contour, are normal from a purely orthodontic stand- 
point. The dental models of these three profiles are shown in 
Figs. 55, 57, and 59, and it will be seen that in each instance 
the teeth are in approximately normal occlusion. 




Showing parts of the face of special interest to the orthodontist : a, chin (mentum); 
b, aperture (rima oris); c, angle (angulus oris); d, philtrum; e, nostrils (nares); f, ala 
(ala nasi); g, dorsum {dorsum nasi); h, frontal eminence; i, root (radix nasi); j, base 
(basis nasi); k, tip (apex nasi); I, nasolabial sulcus; to, cheek (bucca); n, upper lip; 
o, lower lip; p, mentolabial sulcus. 

But prior to a consideration of the effects of malocclusion 
upon the facial lines the student should study Fig. 60, 
which represents the face of a young girl, with the more 
important parts marked in the area which is so frequently 



108 FACIAL DEFORMITIES DUE TO MALOCCLUSION 

affected by orthodontic treatment. Some of the normal 
variations in the arrangement of these parts have been 
recognized by orthodontists. 

Fig. 61 







Neutroclusion complicated by labioversion of the upper and linguoversion of the 
lower incisors. (Compare with Fig. 62.) 



ABNORMAL VARIATIONS OF THE PROFILE 



The various anomalies of dentition which may combine 
in a malocclusion were outlined in Chapter V, and it now 
becomes necessary to describe in detail the deformities of 
the face resulting therefrom. 

In Fig. 61 a photograph is shown of a dental model 
exhibiting a pronounced labioversion of the upper incisors. 
Obviously, such deformity must always affect the contour 



ABNORMAL VARIATIONS OF THE PROFILE 109 

of the soft and yielding tissues of the lips, particularly the 
upper. It will be observed that the occlusion of the first 
molars is normal, there being no arch malrelation, and it may, 
therefore, be classified as a case of neutroclusion. The con- 
sequent distortion of the facial lines is shown in Fig. 62. 

A similar though frequently more pronounced type of 
deformity is shown in Fig. 63. This must not be confused 

Fig. 62 






Facial deformity resulting from the malocclusion shown in Fig. 61. 



with the former, however, for upon closer examination it 
will be seen that though we again have a labioversion of 
the upper incisors, there exists in addition a bilateral disto- 
clusion of the lower (Fig. 64). Any attempt at correction 
of the facial deformity and of the labioversion of the upper 
incisors would prove futile if it did not take into consider- 
ation the distal malrelation of the lower arch. 

Further complications in these types, especially in patients 



110 FACIAL DEFORMITIES DUE TO MALOCCLUSION 

beyond the developmental period, are an abnormal growth 
of the lips, an arrest of development in the alveolar processes, 
and malformations of the jaws. On the other hand, if 

Fig. 63 




V 





Facial deformity resulting from the malocclusion shown in Fig. 64. 
Fig. 64 



'J 


*<n 5 


1 


* »t%™ 


1 

1 




...... . , 



Bilateral distoclusion complicated by labioversion of the upper incisors. 
(Compare with Fig. 63.) 



ABNORMAL VARIATIONS OF THE PROFILE 111 

correction of the malocclusion is instituted early, a restora- 
tion of normal function and subsequent growth of the bony 
structures will take care of the accompanying inequalities 
of facial contour. This rarely, if ever, follows when treat- 
ment is too long postponed. In Fig. 65 a profile is shown of 
a girl, aged sixteen years, with such a deformity completely 
established. Suffering from mouth breathing for a number 
of years, the upper lip, by continual stretching, w^as arrested 

Fig. 65 




Permanent deformity of the upper lip resulting from postponement of treatment 
of the malocclusion shown in Fig. 66. (Compare Fig. 25.) 

in its development, and now remains too short and too 
thin. The lower, on the other hand, found lodgement in 
the space between the upper and lower incisors, and thus, 
through abnormal function, overdeveloped (Fig. GO). 

The reverse of this type of deformity is found in neutro- 
clusions complicated by a linguoversion of the upper incisors; 
in mesioclusions; in arrested development of the maxilla; 



112 FACIAL DEFORMITIES DUE TO MALOCCLUSION 

Fig. 66 




Models of the case shown in Fig. 65. 
Fig. 67 




Facial deformity accompanying the malocclusion shown in Fig. 68. 



ABNORMAL VARIATIONS OF THE PROFILE 113 

and in cases of macrognathism of the mandible. Figs. 67 and 
68 show the casts and photographs of a lad, aged thirteen 
years, where the lack of prominence of the upper lip is 
very apparent. An extreme form of micrognathism of the 
maxilla, with distoclusion of the upper arch and infraversion 
of the anterior teeth, and the consequent facial deformity, 

Fig. 68 




Unilateral mesioclusion, resulting in deformity of the profile shown in Fig. 67. 



are shown in Figs. 69 and 70. Though similar to the former 
in outward appearance, the latter must not be considered 
as belonging to the same group, or to the next and even 
more serious type (Figs. 34 and 35). The latter is a case of 
mandibular macrognathism, of which the accompanying 
mesioclusion of the lower arch and mesioversion of the lower 
teeth are but symptoms. To overlook the mandibular 



114 FACIAL DEFORMITIES DUE TO MALOCCLUSION 

Fig. 69 




Maxillary micrognathism. 
Fig. 70 




Profile of case shown in Fig. 69. 



ABNORMAL VARIATIONS OF THE PROFILE 115 

deformity in such a case is to utterly fail in the diagnosis. 
Indeed, all dentofacial deformities, of whatever type, are 
but symptoms of the underlying, and therefore more 
fundamental, dental anomalies. 

Fig. 71 




Deformity due to curvature of the mandible. 



The so-called "open bite" (Fig. 41, B) is a deformity 
commonly associated with nasal obstruction, and may. com- 
plicate either neutroclusion, mesioclusion, or distoclusion. 
Very rarely it may be due to a curvature of the body of 
the mandible (Fig. 71). Attention must also be directed 
to the fact that in the unilateral forms of distoclusion 



116 FACIAL DEFORMITIES DUE TO MALOCCLUSION 

and mesioclusion the same facial deformities may exist as 
in the bilateral types, though they are usually less severe. 

Another type of deformity is that associated with supra- 
version of the incisors, which may be symptomatic of neutro- 
clusion or of distoclusion; and in all of these the outer contour 
of the facial muscles involved, particularly of the lower lip, 




Neutroclusion accompanied by the facial deformity shown in Fig. 73. 

appear so crowded that it suggests overdevelopment. But 
this is usually more apparent than real, because after the 
correction of the malocclusion they readily assume a normal 
form. The author is convinced, moreover, that the really 
serious condition met with in many of these cases is a lack 
of perpendicular development in the region of the symphysis. 
In other words, the distance from the gingival line of a lower 



ABNORMAL VARIATIONS OF THE PROFILE 117 

central incisor to the mental eminence of the chin is too 
short. This condition is the source of much annoyance to 
the operator during treatment, and extremely difficult to 
permanently correct. 

The normal variations of the symphysian angle have 
already been referred to. Figs. 72 and 73 show a case where, 
besides exhibiting considerable malocclusion of a type 

Fig. 73 




Showing extreme deficiency of the symphysian angle. 

ordinarily demanding a liberal expansion of both the upper 
and lower arches, a compromise in treatment would seem 
to be indicated. The receding chin, in this instance, is a 
fundamental osseous condition which must be reckoned 
with, and which no amount of tooth movement at this late 
period (the patient being sixteen) would ever correct. 



118 FACIAL DEFORMITIES DUE TO MALOCCLUSION 



ORTHODONTIC CONCEPTIONS AND IDEALS 

The mere fact that orthodontics embraces methods for 
the correction of deformities of the face predicates the 
desirability of a standard, or criterion of judgment. 



Fig. 74 



Fig. 75 





Classical profile of Apollo. 
(After Farrar.) 



Measurements employed by artists. 
(After Wiegall.) 



"The duties of the orthodontist force upon him great 
responsibilities, and there is nothing in which the student 
of orthodontia should be more keenly interested nor better 
informed than in the study of the artistic proportions and 
relations of the features of the human face; for each of 
his efforts, whether he realizes it or not, makes for beauty 
or ugliness, for harmony or inharmony, for perfection or 






ORTHODONTIC CONCEPTIONS AND IDEALS 119 

deformity." 1 Furthermore, besides forming an important 
phase of the difficult art of diagnosis, it involves us in "the 
most remarkable problem of esthetics/' viz., that of beauty 
of form. Ignorance of these requirements has led numerous 
operators into the unenviable position of having permanently 
marred the beauty of an otherwise handsome face. 

In the works of Kingsley, Farrar, Jackson, etc., the need 
for some standard as an aid in diagnosis was plainly felt. 
The classical profile of the Grecian mythological god 
Apollo (Fig. 74) and the lines of division employed by 
artists in the study of v esthetics (Fig. 75) have been widely 
used for this purpose. But not until Case 2 and Angle 3 
developed their comprehensive systems did we approach 
methods of tolerable accuracy. Unfortunately, a review of 
the works of these two authors reveals the fact that their 
conclusions are diametrically opposed to each other. 

Case's Ideal. — A large experience and much careful obser- 
vation have led Professor Case to formulate the following 
principles : 

"The portion of the human face that it is possible to 
change with dental regulating apparatus may be said to lie 
between two diverging lines which arise at a point below the 
ridge of the nose and curve downward to enclose the alse 
and depressions on either side; thence laterally to encircle 
a portion of the cheek, and downward to enclose the entire 
chin (Fig. 76). This area may be termed the changeable 
area in contradistinction to the more stable features, or 
unchangeable area. For convenience of ready reference, the 
features in that portion of the changeable area which are 

1 Angle, Amer. Text-book of Oper. Dentistry, 3d ed., p. 694. 

2 Dental Orthopedia, 1908. 

» Malocclusion of the Teeth, 7th ed., 1907. 



120 FACIAL DEFORMITIES DUE TO MALOCCLUSION 

bounded laterally by the nasolabial lines may be divided 
into four segments, as follows: 

"Segment 1. The end of the nose and the upper portion 
of the upper lip, including the nasolabial depressions. 

"Segment 2. The lower portion of the upper lip. 

"Segment 3. The lower lip. 

" Segment 4. The chin. 

"These four segments are changeable in their relations 
to each other, and also in their individual relation to 
features in the unchangeable area." 

Fig. 76 



Unchangeable area - 



Changeable area 




Method of measurement. (After Case.) 



Dr. Case further maintains that the relations of these 
areas to each other must be determined prior to treatment 
by the trained eye of the operator, and the deviations, if any, 
noted. Following this the treatment must be planned so 
as to produce the best possible exterior effects or contour 
of these parts. In other words, the operator's ideal of facial 



ORTHODONTIC CONCEPTIONS AND IDEALS 121 

form is the standard or criterion he would have accepted. 
It is presumed, of course, that this be a cultivated ideal, 
carrying with it that fine discretionary ability to say when 
teeth shall be extracted, or moved bodily, for the improve- 
ment of facial balance. According to this author, the full 
complement of teeth is not necessary in the treatment of 
certain types of malocclusion; in some instances extraction 
of one or more teeth is positively indicated. 

Fig. 77 





Shows the unrelatedness of beauty of form and beauty of elements. 
(After Santayana.) 



Theoretically, this is perhaps true, because "Beauty of 
form cannot be reduced to beauty of elements. All marble 
houses are not equally beautiful." Similarly, all profiles, 
even though they are moulded over an ideal occlusion of 
all the permanent teeth, are not equally beautiful. "All 
ideal forms have an emotional tinge. Beauty of form is due 
to expression, and all expression, ultimately, is something 
else than beauty — some practical or moral good." For 
example, "take the ten meaningless short lines in Fig. 77, 



122 FACIAL DEFORMITIES DUE TO MALOCCLUSION 

and arrange them in the given ways intended to represent 
the human face; there appear at once notable different 
esthetic values. Two of the forms are differently grotesque, 
and one approximately beautiful. These effects are due to 
the expression of the lines ; not only because they make one 
think of fair or ugly faces, but because, it may be said, these 
faces would in reality be fair or ugly according to their 
expression, according to the vital and moral associations of 
the different types." 1 

Angle's Ideal. — But according to Angle, "We must be able 
to detect whether the features — that is, the forehead, the 
nose, the chin, the lips — of each individual face balance, 
harmonize, or whether they are out of balance, out of har- 
mony, and especially whether the mouth is in harmonious 
relations with the other features, and if it is not, what is 
necessary to place it in balance. The faculty of determin- 
ing the proper balance of the features is a difficult one to 
attain." Quoting Prof essor Wuerpel, he further says : "Only 
one in two or three hundred art students ever succeed in 
mastering it, and these only after much observation and 
practice in sketching and modelling of faces. Unpromising 
as this seems, it is doubtless correct; yet we have a rule for 
determining the best balance of the features, or, at least, 
the best balance of the mouth with the rest of the features, 
that artists probably know nothing of, and one that for the 
orthodontist is more unvarying and more reliable than even 
the judgment of the favored few — a rule so invariable and 
with so few exceptions that we may consider it a law, and 
if it be not applicable in all cases, the exceptions will be 
so very rare that they are hardly worth considering. It is, 

1 Santayana, The Sense of Beauty. 



ORTHODONTIC CONCEPTIONS AND IDEALS 123 



Fig. 7S 




Shows the author's method for estimating in advance the probable effect 
of an orthodontio treatment. (Compare with Fig. 79.) 



124 FACIAL DEFORMITIES DUE TO MALOCCLUSION 



furthermore, a rule so plain and so simple that all can under- 
stand and apply it. It is thai the best balance, the bed harmony, 
the best proportions of the mouth, in its relations to the other 
features, require that there shall be the full complement of teeth, 
and that each tooth shall be made to occupy its normal position 
— normal occlusion.' " 

Fig. 79 






Photographs of the patient before and after the use of the wax mould 
shown in Fig. 78. 

Expressed differently, Angle maintains that the outward 
form of the changeable area of the face is dependent upon 
the relative normality of the denture within; and that, as a 
rule, it is best to establish normal occlusion (which implies 
the presence of each tooth), and thus strike a balance which 
is rarely wrong. Theoretically, this is not absolutely true; 
and it can hardly be called a law, using the word in its 
scientific sense. Bat many operators of wide experience are 
practically unanimous in support of his contention, hence it 



ORTHODONTIC CONCEPTIONS AND IDEALS 125 

has become a fundamental postulate in orthopedic practice. 
In other words, it is true because it ought to be true, and 
because the opposite practice of sacrificing teeth for the 




Method employed in distoclusions. (Compare with Fig. 81.) 



126 FACIAL DEFORMITIES DUE TO MALOCCLUSION 



improvement of facial contour is rarely necessary, and 
seldom advantageous. Indeed, the necessity for the extrac- 
tion of one or more teeth is so infrequent that its practice 
has become almost obsolete. This is particularly true in all 
cases where the treatment is instituted during the develop- 
mental period. The development of the surrounding osseous 
structures subsequent to tooth movement is usually to be 
expected in young patients; hence their profile must never 
be considered as a fixed line (at least not immediately after 
treatment), but one in which further changes will continue 
to take place. 

Fig. SI 




r THY *J 

Shows temporary effect upon the profile 




DIAGNOSTIC METHODS 



In order to ascertain in advance the probable effect of 
treatment upon the facial lines, the author has used the 
following methods whenever applicable. 



DIAGNOSTIC METHODS 



127 



In cases of neutroclusion accompanied by linguoversion 
of the incisors, a piece of softened wax is moulded over the 



Fig. 82 




Same method as in Fig SO. 



128 FACIAL DEFORMITIES DUE TO MALOCCLUSION 

occluded models and trimmed to a form approaching the 
future alignment of these teeth (Fig. 78). After it has 
been allowed to cool it is placed in position in the mouth. 
The patient is now asked to relax all tension of the lip 
muscles, which allows the facial lines to assume the form 
which the treatment will ultimately produce (Fig. 79). 



Fig. 83 





Photographs of case shown in Fig. 82. 



In distoclusion accompanied by labioversion of the 
upper incisors (Fig. 80, a) the patient is requested to bite 
mesially, so as to bring the first molars into normal mesio- 
distal relations. Fig. 81 clearly shows the effect upon the 
facial lines, representing photographs of the patient with 
the teeth in the positions shown in Fig. 80, a and 6. Simi- 
lar preliminary studies can be made of patients presenting 
a distoclusion accompanied by linguo version of the upper 
incisors. The latter type frequently combines with supra- 



DIAGNOSTIC METHODS 129 

version of the incisors and infraversion of the molars and 
bicuspids, for which Dr. Case 1 has suggested a temporary 
"opening of the bite." If necessary, pieces of modelling 
compound, or wax, are previously inserted to prevent 
complete closure, and while in this position a study of 
the profile can be made (Figs. 82 and 83). 

In the more serious cases of facial deformity, e. g., those 
due to mandibular macrognathism or to infraversion of the 
incisors, these methods are inapplicable. 

i Dental Orthopedia, p. 323. 



CHAPTER VII 

THE PROGNOSIS OF MALOCCLUSION 

DEFINITION 

The medical term prognosis is used to denote the probable 
result of, or prospective recovery from, a disease or abnor- 
mality. It is an opinion concerning the duration, course, 
and termination of a disease and of the outcome of the 
treatment. And while such judgments necessarily vary in 
accordance with an operator's experience, they are, never- 
theless, dependent upon conditions inherent in each case. 

In orthodontic practice it frequently becomes necessary to 
render an intelligent opinion in advance of treatment; and 
it is well to remember that a favorable prognosis depends 
largely upon an early diagnosis, when conditions are such 
that a comparatively simple treatment will suffice. For- 
merly it was customary to postpone most treatments until 
all of the permanent teeth had erupted, for it was believed 
that nature would assist in the correction of the malocclusion, 
and that most patients would "outgrow" the deformity. 
Many bitter disappointments have taught us the error of 
such advice, and strongly emphasize the fact that the severe 
forms of malocclusion do not develop over night, but are of 
slow growth. Hence it follows that years before even an 
intelligent parent recognizes the impending deformity, the 
alert diagnostician can advise ways and means for its 
prevention. 



GENERAL CONSIDERATIONS 131 



GENERAL CONSIDERATIONS 

Age and Health. — Age and health may be regarded as funda- 
mental considerations in every prognosis. Thus a macrog- 
nathic mandible, accompanied by mesioclusion of the lower 
arch, might readily yield to treatment between the eighth 
and tenth years. On the other hand, if such a condition is 
neglected until the twentieth year the deformity might then 
be so severe that orthodontic measures for its correction 
would prove futile. Similarly, if treatment is attempted in 
two cases of the same age and type, but with widely divergent 
conditions of general and oral health, their response to treat- 
ment might vary considerably. Let us suppose that in 
one case immunity to caries had always existed; that the 
patient's robust health permits the operator to carry the 
treatment to a rapid and successful conclusion. In the 
other, we find caries very progressive, and the oral secretions 
markedly abnormal; the patient is hypersensitive and 
enfeebled by prolonged illness. It is obvious that in the 
latter, response to treatment will be extremely slow or 
plainly doubtful, even though it be administered by the 
same experienced hands. To be able to detect such differ- 
ences in advance is often difficult, and the ability to do so 
can only be acquired by a wide experience and much careful 
observation. 

Sex. — Dr. Guilford 1 has pointed out that the question of 
sex may enter into a prognosis, and claims that "a robust 
boy can undergo an operation that in a tender girl might 
result in nervous shock or even greater physical harm." 
He rightly maintains that a "loss of general health could 

1 Orthodontia, 4th ed., p. 41. 



132 THE PROGNOSIS OF MALOCCLUSION 

never compensate for an improvement of the dental organs, 
however great." Other writers assert that sex is of little 
consequence, and they are unwilling to accept a comparison 
between a "robust boy" and a " tender girl," because there 
are many robust girls who make better patients than tender 
boys. However, it appears self-evident that the advent 
of puberty in females, with its frequent disturbances of 
bodily equilibrium, requires the exercise of more than 
ordinary care and attention; all of which emphasizes the 
necessity for early treatment. 

Furthermore, the methods of today are such that, when 
properly administered, they do not act as a hardship on the 
patient. It is unfortunate, therefore, that the cry of an 
ignorant laity should raise an echo in the profession, leading 
to a denunciation of orthodontics, and the claim that its 
treatments seriously undermine the health of many indi- 
viduals. Dr. Ketcham 1 and others have gathered data in 
refutation of these false assertions, and have found that 
practically all patients gained in weight during the entire 
period of orthodontic treatment; many of them improved 
rapidly in their studies at school, and few failed to respond 
favorably to treatment. This ought not to cause surprise 
when we consider that most parents are sufficiently careful 
not to demand orthodontic services for their sick children. 

A well-meant, though misdirected, enthusiasm has 
prompted some operators to ignore entirely the factors of 
age and sex, and to accept cases of advanced years. Most 
of these patients are women who suddenly desire amends 
in facial expression, but with expectations entirely beyond 
the achievable. Though a carefully executed orthodontic 

1 Dental Cosmos, September, 1910. 



SPECIAL CONSIDERATIONS 133 

operation usually improves the facial lines, there are many 
instances where the results could hardly be called beautiful, 
and for which the operator is in no wise responsible. Let 
the beginner beware, therefore, of all mature cases with a 
doubtful prognosis ; especially in the cases of married women, 
with the ever-present possibility of an intervening preg- 
nancy. The latter constitutes an exceedingly unfavorable 
condition, rendering post-treatment maintenance extremely 
doubtful, if not impossible. 



SPECIAL CONSIDERATIONS 

One of the most important factors entering into a prognosis 
is that of cause, the ignoring of which has led to many 
failures. The removal of the cause, whenever possible, is 
the first step in successful treatment. Of course, in a great 
many instances (owing to our limited knowledge of this 
subject) we are unable to proceed in this manner; but this 
makes it all the more imperative to do so in all cases where 
the cause is readily recognized. By way of illustration, let 
us consider the case shown in Figs. 84 and 85, exhibiting 
abnormal breathing. This symptom connotes nasal obstruc- 
tion, which usually stands in causal relation to the mal- 
occlusion. Its presence and neglect in early childhood 
invariably leads to malocclusion of the permanent teeth, 
and in all cases associated with mouth breathing the com- 
petent treatment of the abnormal nasal conditions should 
be insisted upon. (Compare with Fig. 41,-4, which is from 
a patient of similar type at the age of sixteen.) 

Owing to the mechanical aspects of dentition, the self- 
correction of most forms of malocclusion is an impossibility. 



134 THE PROGNOSIS OF MALOCCLUSION 

Fig. 84 




Facial deformity in a lad of eight years suffering from nasal obstruction. 
Fig. 85 




Denture of case shown in Fig. 84. 



SPECIAL CONSIDERATIONS 



135 



Nature and time rarely exercise a corrective influence upon 
them. To the usual questions, then, which parents so 
frequently ask in first consultation, a negative answer is 
uniformly best. The accompanying facial deformities, which 
are often the immediate reason for their inquiries, grow 
steadily worse. Fig. 86 shows the models of a lad, aged 

Fig. 86 




Incipient unilateral distoclusion at eighth year. 



eight years, whose parents found it convenient to heed the 
advise of an ignorant dentist: " Hell outgrow that in a few 
years. I wouldn't advise any treatment now." These and 
many similar assertions are soothing to a father's purse. 
During the few minutes this boy occupied the author's 
operating chair, and while his remarks on the urgent neces- 
sity for treatment were slowly and emphatically expressed, 



Fig. 87 




Same case as Fig. 86 at age of fourteen. 
Fig. 88 




Facial deformity accompanying case shown in Fig. 87. 



SPECIAL CONSIDERATIONS 137 

the impressions from which these models were made were 
taken. Under pressure, probably, of the conflicting social 
and economic tendencies of our age, this lad and his parent 
disappeared from the immediate scene. Six years elapsed 
before their return, during which time the models rested 
peacefully in their place in the cabinet. Another dentist is 
now caring for this family's dental ills, and their return to 
the author's office is not an unusual or unexpected incident. 
Fig. 87 shows the same denture at the age of fourteen, and 
Fig. 88 the pronounced deformity of the face which time 
and nature, unaided, had wrought. The history of many 
similar maldevelopments could here be introduced; they are 
all too common, even in this day. But multiplication is 
unnecessary. Every fact gleaned from a study of the process 
of dentition substantiates the orthodontic axiom that mal- 
occlusion and its accompanying deformities are progressive, 
not static. In short, the prognosis of malocclusion is equally 
as unfavorable as of caries of the enamel; the evil conse- 
quences are equally certain. The old adage, "An ounce of 
prevention, etc.," is decidedly apropos in a consideration 
of malocclusion of the teeth. 

The one great lesson, then, which recent orthodontic 
progress teaches is that all forms of malocclusion develop 
slowly; that during childhood they are ever in process of 
development. To appreciate this evolution of types, to 
detect them in their incipiency, and to divert the underlying 
forces into channels of normality — this is the highest mission 
of orthodontics. But there is another lesson which must be 
more widely taught than formerly, and which has been too 
much neglected, namely, the important relation a normal 
denture bears to health. In earlier periods orthodontic 
efforts were appreciated mainly for their esthetic conse- 



138 THE PROGNOSIS OF MALOCCLUSION 

quences; the desire for an improvement of facial harmony 
was the prime motive in most instances. More recently 
we have come to a realization of the fact that a normal 
denture implies normal occlusion, without which its efficiency 
is greatly reduced. 

The recent experiences of many practitioners have led us 
to a keener appreciation of the "golden age for treatment/' 
by which we mean that time in an individual's life when the 
change from the temporary to permanent dentition takes 
place. This covers the period from the sixth to the four- 
teenth year. In rare instances (those cases which early 
exhibit a tendency toward extreme malformation of the 
jaws) it has been found advisable to begin treatment prior 
to the sixth year. And in most cases of mesioclusion or disto- 
clusion it is best to institute treatment as soon as it can be 
diagnosed, i. e., immediately after the eruption of the four 
first permanent molars. 

The establishment of the alveoli and the complete cal- 
cification of the roots of the teeth; the development of 
the temporomandibular articulation; the lengthening of the 
rami and the development of the body of the mandible — 
all these are considerations which must be reckoned with. 



CLINICAL SUMMARY 

A brief study of the various forms readily establishes the 
conclusion that in their earliest stages all are comparatively 
simple. Figs. 89 and 90 show two cases of distoclusion; 
one aged nine years, the other fourteen. In Fig. 89 it will 
be noticed how the linguoversion of the upper central 
incisors prevents a normal mesiodistal relation of the lower 



Fig. 89 




Incipient bilateral distoclusion at nine years. 
Fig. 90 




Same type of malocclusion at fourteen years. 



140 



THE PROGNOSIS OF MALOCCLUSION 



arch; the tendency is toward an arrest of development of 
the mandible. Note further how the molars are thereby 
prevented from coming into normal occlusion. A moment's 
comparison establishes the inference that the older case 
(Fig. 90) passed through a similar stage. 



Fig. 91 




Bilateral mesioclusion at eleven years. 



That the history of mesioclusion is similar is equally 
certain is shown by a comparison of models in Figs. 91 and 
92. Fig. 91 is made from the denture of a boy, aged eleven 
years, while Fig. 92 is from an adult, aged twenty-eight 
years. It is inconceivable how neglect could prove beneficial 
to Fig. 91; it is the surest way toward a multiplication of 
difficulties. If the influences of abnormal function, of the 



CLINICAL SUMMARY 



141 



impacts during use, are considered, it becomes evident that 
the omission of treatment constitutes a "penny- wise and 
pound-foolish policy." How an intelligent dentist, intrusted 
with the care of the mouths of growing children, could permit 
such abnormal developments under his very eyes and not 
remonstrate against them is incomprehensible. The probable 





Fig. 92 




fc^PB 


... ■ , ^ ' ' 






£, ****^&if^^m{ 




\MfJ 


""""^KL hi 

a j*~ -*r -4t S^j| 




K 







Mandibular macrognathism at twenty-eight years. 

result of treatment for Fig. 91 is exceedingly favorable; the 
correction of the mandibular macrognathism of Fig. 92 
lies beyond the domain of orthodontics. (See Chapter 
XVIII.) 

In the next illustration (Fig. 93) we note a distoversion 
of the upper centrals in a girl, aged eight years, due to an 



142 



THE PROGNOSIS OF MALOCCLUSION 



abnormal frenum labium, and another (Fig. 94) at the 
age of twelve. Four years of neglect have again demon- 
strated their evil consequences. The diastema between the 



Fig. 93 




Denture of a girl, aged eight years. 
Fig. 94 




Similar type at the age of twelve. 



CLINICAL SUMMARY 143 

centrals caused an encroachment upon the lateral spaces, 
and when the latter finally appeared they readily erupted 
lingual to normal. A further study of many similar cases 
might here be introduced, but the lesson from each would 
be substantially the same. To the question then, Is early 
treatment always advisable? the uniform reply is Yes. 
Should postponement of treatment be desirable in a given 
case, the operator should be accorded the privilege of the 
decision. 

As to treatment, MacDowell 1 has suggested a classification 
of cases into three groups, as follows: 

The possible: all cases between the ages of eight and 
fourteen. 

The probable: mesioclusions and distoclusions after the 
age of fourteen. 

The impossible: most cases beyond the age of sixteen. 

Skilful orthodontists regard this as a very conservative 
classification, because a wide experience enables them to 
considerably extend the age limit of each group. But the 
beginner will find it a valuable guide, it being the part of 
wisdom to err on the side of safety. 

1 Orthodontia, xvii. 



CHAPTER VIII 

THE EVOLUTION OF METHODS 

METHODS OF THE PAST 

Scientific progress during the last half century has so 
altered our conceptions regarding the theory of life and the 
growth of society, that we are forced to re-write history 
and adapt it to the evolutionary philosophy (Pearson 1 ). 
Present-day standards require history to be more than 
antiquarian; the real profit in tracing the development of 
an art must rest in something else than a mere knowledge 
of what has happened in chronological order; it must dwell 
in an understanding of the principles that have promoted 
the developments of the past, in the meaning of certain 
events. This advance in our conceptions is due to the 
epoch-making labors of Darwin, "who made all reasoning 
since his day follow his method." 

Now, in tracing the evolution of orthodontics the aim 
should be to view its development from the standpoint of 
this new and higher perspective. In no other division of its 
subject matter is this more desirable than in the methods 
of treatment. Not that the tracing of its remedial measures 
constitutes the whole of its history; the evolution of the 
science and the history of its theoretical foundations are 
equally important. But a greater unanimity of opinion 

1 The Grammar of Science. 



METHODS OF THE PAST 145 

regarding these fundamentals has always existed. Indeed, 
the principles of the science are readily traced; in these 
fields a greater harmony prevails than a first survey seems to 
justify. Not so with the art. The steep aclivity up which 
we have so slowly traveled measures a progress not without 
interest or strife. The desire for supremacy on the part 
of several of our leaders has added its bitterness as well as 
charm. 

The delineation of the methods of treatment is difficult 
not only because they have been as varied as could well be 
imagined, but because they comprise an overwhelming mass 
of trivial details. Formerly, the dentist only occasionally 
dabbled in matters orthodontic, and thus failed to grasp 
the principles underlying the technical details of treatment. 
Prior to diagnostic systems each case constituted a class 
by itself, so that the designing and constructing of a mechan- 
ism for treatment often taxed to the utmost the inventive 
capacities of the practitioner. Thus the birth of the new 
order was painfully prolonged, and the rudiments of present- 
day methods unwittingly obscured. 

But in 1878 Dr. Farrar, of New York (see page 27), 
prophesied lines of advance which have since been followed 
with increasing advantage and favor. The import of his 
prediction was not readily grasped, though it stipulated 
the standardization of appliances and their being carried in 
stock by dealers. Indeed, this ideal is not yet fully achieved, 
though its influence thus far has been nothing short of 
revolutionary. It has forever relegated appliance manufac- 
ture where it rightfully belongs, has freed the mind of the 
operator of many petty details, and furnished the necessary 
leisure for the investigation of more important matters. 

Viewed in this wise, it is not difficult to imagine the 
10 



146 



THE EVOLUTION OF METHODS 



probable present status of a department like operative 
dentistry had not the manufacturer long ago come to the 



Fig. 95 




Fauchard's metallic alignment band (1728). (After Pfaff.) 
Fig. 96 




Schange's appliance (1840). (After Pfaff.) 

rescue. The wonder of it, then, is not how little, but how 
much the past has achieved. Truly, a sincere review of the 



METHODS OF THE PAST 147 

work of the pioneers and pathfinders awakens the deepest 
reverence; their labors must ever be regarded as indispen- 
sable stepping stones. Though they are now fading from 
twilight into dusk, let us not forget that they ushered in 
that golden dawn which made the present possible. 

Fig. 95 shows an appliance used by Fauchard (1728), and 
exhibits the principle of our present-day alignment wire. 
Fig. 96 shows an appliance designed by Schange (1840), and 
embodies the essentials of mechanisms in use today. A 

Fig. 97 




±JJ^ 



Flagg's round alignment wire (1865). (After Pfaff.) 

similar, though greatly simplified, apparatus is shown in 
Fig. 97, being a design by Flagg (1865). It represents the 
round alignment wire, with flattened ends anchored to the 
molars, and serves as a goal toward which the malposed 
teeth are moved by means of ligatures. A comparative 
study of other elements might easily be here introduced, 
though a sufficient number have been shown to demonstrate 
their gradual evolution. Some systematists have studiously 
avoided such comparative study, and utilized well-chosen 
contrasts to their own advantage. 



148 



THE EVOLUTION OF METHODS 



RISE OF THE SYSTEMS 

Following the epoch-making labors of Farrar, the intro- 
duction of stock appliances was inevitable. The wholesale 
construction of standard mechanisms with interchangeable 
parts, to be placed upon the market for sale, was now 




Farrar's "labial bow" and clamp bands. 
Fig. 99 




Patrick's appliance. 

demanded. Naturally, many of the earlier efforts in this 
direction were very incomplete and unsatisfactory, and in 
untrained hands often proved a failure. They were usually 
brought forth in the shape of a " system," and represented 
the more commonly used methods of their author. 



RISE OF THE SYSTEMS 



149 



In 1876, in response to these demands, Dr. Farrar offered 
duplicates of many of the appliances he had used in his 
practice (Fig. 98). For a time they enjoyed an extended 
sale, but were soon displaced by devices of simpler design, 
notably those by Patrick in the early 80's (Fig. 99). A 
study of this illustration reveals the principle of the align- 
ment wire anchored to the molars by means of adjustable 
bands with buccal tubes. 

Fig. 100 




Angle appliance of 1887. 



In 1887 Angle introduced a system which embodied 
sundry of these old principles, though greatly simplified 
by a reduction of parts (Fig. 100). 

Among the many other methods brought forward during 
this unusually productive period were the systems of Jack- 
son, Case, Lukens (Fig. 101), and Knapp. 



150 



THE EVOLUTION OF METHODS 



Recent adverse criticism has created considerable ill 
feeling in opposition to these so-called systems, which could 
easily have been avoided had their originators adhered to 
the principles of historical method. Their tacit claims of 



Fig. 101 




Lukens' appliance. 



having suddenly, and by original methods, revolutionized 
the art and brought it to an approximate finality, are 
directly traceable to the wilful omission of the work of 
many predecessors. 

In Chapter I attention was called to their achievements, 
to their influences toward the simplification of methods; 



LINES OF ADVANCE 151 

and so the struggle which they themselves engendered may 
be regarded as a passing cloud — for systems are wholly 
foreign to the democracy of science. Hence the thought 
that they must finally die, that upon their shattered dreams 
of finality a greater and grander art will rise, is encouraging, 
and not at all dispiriting. Indeed, this forward movement 
has now begun. 

LINES OF ADVANCE 

The comprehension of the importance of a differential 
diagnosis, the designing of a definite treatment for all cases 
belonging to a given class, and the simplification and mastery 
of the technical details of every such definite treatment, may 
be said to constitute the core of what has been termed the 
new movement in orthodontic practice. 

The systems (particularly the efforts of Angle) have been 
largely responsible for promoting this advance in our 
progress. And though they were unbecomingly dogmatic, 
they possessed the saving grace of showing the wide range 
of applicability of a limited number of very simple mechan- 
isms. Hence the burden of their claims was, after all, a 
very laudable one; by insisting on the mastery of a few essen- 
tials and their manifold combinations, orthodontics made a 
progress hitherto unattainable. In fine, to be a master in 
the application and use of a few appliances, rather than 
the slave of many, is a worthy lesson the systematists have 
tried to teach. Ever since the dawn of this tendency toward 
simplicity and. the unification of methods, orthodontics 
has witnessed a wholesome elimination of many unneces- 
sary and impractical procedures. Though this process of 
elimination still continues, at the present writing it is very 



152 THE EVOLUTION OF METHODS 

evident that certain mechanisms (those embodying advanced 
principles of design) are tending rapidly toward universal 
acceptance. 

DETAILS OF DESIGN 

Fig. 102 is diagrammatic of a modern appliance, combin- 
ing many of the essential elements in use today. These 
elements may briefly be summarized as follows: The plain 
band (B), anchor band (D), alignment wire (F), ligatures 
(C and A), and a number of minor miscellaneous accessories 

Fig. 102 




Modern appliance. (After Angle.) 

not shown in the illustration. By the skilful and judicious 
combination of these elements we are enabled to treat most 
cases of malocclusion. Only rarely are we obliged to employ 
other and more complicated appliances. 

From the earliest times, several of the noble metals, viz., 
gold, platinum, silver, and their alloys, have been used in 
the construction of regulating appliances. In recent years 
base metal alloys like German silver have been widely 
employed. Iron, steel, nickel, aluminum bronze, and 



DETAILS OF DESIGN 153 

vulcanite rubber have all been recommended. German 
silver, however, possesses many of the virtues which should 
be embodied in an appliance, such as temper, adaptability 
when annealed, inexpensiveness, etc. On the other hand, 
Pullen 1 and Grieves 2 have recently called attention to its 
shortcomings, which are as follows: Discoloration and 
disintegration, and, occasionally, the formation of metallic 
stains upon the tooth surfaces. 

Alloys of iridium and platinum, and of gold and platinum, 
are therefore preferred by many operators, because they 
are not affected by the acid fluids of the oral cavity, or by 
any of the medicaments employed in practice (such as 
hydrogen peroxide, solutions of silver nitrate, tincture of 
iodine, etc.). 

When attention was first called to the corrosion of German 
silver, its advocates proclaimed this a virtue, believing the 
consequent liberation of metallic salts had a favorable 
prophylactic influence, promoting an immunity to caries of 
the enamel. Grieves, 3 on the other hand, has shown that 
the amount of metallic salts thus set free and swallowed 
by the patient frequently proves deleterious by unfavorably 
affecting the physiological action of the ptyalin and enzymes. 
He claims zinc is the most objectionable of all the metals 
which enter into alloys used for appliances. 

The introduction of aluminum bronze into dentistry by 
Sauer, and its recent revival for regulating appliances by 
Treymann, 4 resulting in the so-called "non-corrosive" 
appliances, will doubtless lead to the discovery of base- 
metal alloys with virtues equal to those of the noble metal 
group. The latter, however, possess all of the requisite 
qualifications except that of cost. 

1 Proc. Amer. Soc. Orthodontists, vol. vii. 2 Ibid., vols, viii and ix. 

3 Loc. cit. 4 Vierteljahr. f. Zahnhk., July, 1909. 



CHAPTER IX 

PRINCIPAL ELEMENTS OF MODERN MECHANISMS 

BANDS 

The Plain Band. — The individual movement of malposed 
teeth and the correction of arch form constituted the sum 
total of orthodontic efforts for many decades. Only recently 
have the possibilities of arch movement been developed. 
Even in those earlier stages of progress was the need plainly 
felt for some form of attachment to the teeth to be moved. 
Owing to the unfavorable forms of many of the teeth, the use 

Fig. 103 





The plain band. 

of simple ligatures often proved inadequate for the move- 
ments required. To gain secure attachment at the point 
of attack, regardless of the kind of mechanism employed, 
is the first requisite of successful therapy. Hence the plain 
band was invented (Fig. 103). It consists of a ribbon of 
metal 36 to 38 gauge, accurately adapted to the crown of 
the tooth for which it is designed, after which its free ends 



BANDS 



155 



are united by solder (S) to form a continuous band, or 
ferrule. 

As early as 1815 Delabarre 1 suggested the use of metallic 
caps, or crowns, for the teeth to be moved, and to which 
the various attachments were soldered. In 1848 Jos. 
Linderer 2 advocated ribbons of metal for the same purpose. 
These had perforations in their ends, through which ligatures 
were passed, making them adjustable as to size (Fig. 104). 

Fig. 104 




Linderer's adjustable band on the canine. (After Pfaff.) 

Magill and Gilmer have been credited with the honor of 
introducing the plain band as used today, and of advocating 
its secure attachment bv means of cement. While manv 



1 Odontologische Beobachtungen, Paris, 1S15. 

2 Handbuch der Zahnheilk., Berlin, 1848. 



156 PRINCIPAL ELEMENTS OF MODERN MECHANISMS 

minor tooth movements are possible without its use, it is 
evident that the plain band with its various attachments 
will always occupy a prominent place in the technique. A 
detailed consideration of these various attachments and 
their uses will be found in the chapters on treatment. 

The Anchor Band.— This essential element of an appliance 
has passed through many stages, all of which can readily 
be grouped under the two divisions of adjustable and non- 
adjustable. The non-adjustable designs were the first to be 
used, and were variously described as crowns, cribs, clasps, 
and ferrules. They were constructed by the operator, and 
prior to the introduction of cement were very insecure in 
their anchorage, besides promoting caries of the enamel. 

The ferrule design, which, in reality, was a plain band, 
proved the most efficacious of these, and still continues in 
use. With the introduction of the adjustable form of anchor 
band, it was claimed that an accurate adjustment was more 
readily obtained. Owing to the fact that anchorage is 
usually applied to the molars, the crowns of which are less 
accessible than those of the anterior teeth, the adjustable 
designs readily met with great favor. Furthermore, the wide 
use of stock appliances aided materially in their adoption. 

As stated, Linderer was probably the first to use an 
adjustable band. A decided advance in design is shown in 
Fig. 105, which was introduced by Schange in 1841. x He 
adopted the principle of the threaded bar, or screw, for 
adjusting the size of the band. Later, in the hands of 
Farrar, it passed through various stages (Fig. 106). The 
screw-block on the buccal surface was modified by Patrick 
(Fig. 107) and Angle (Fig. 108) into the tube in use today. 

1 Precis sur le redressement des denta, Paris, 1841. 



BANDS 



157 



Even this tube, which provides anchorage for the alignment 
wire, has been modified in design by Knapp, Kemple, Otto- 
lengui, and others. An ingenious modification is shown in the 
design by Lukens (Fig. 109), in which the tube is threaded 



Fig. 105 




Schange's adjustable band on the central. 
Fig. 106 Fig. 107 Fig. 108 





Farrar's adjustable anchor 
band for molars. 



Patrick's adjustable 
anchor band. 



Angle's adjustable anchor 
band. 



on its outer surface and thus made to serve as the screw- 
post, which does away with the attachment of the latter 
on the lingual surface. 

Fig. 110 shows the so-called all-closing, or continuous 



158 PRINCIPAL ELEMENTS OF MODERN MECHANISMS 

form suggested by Barnes. This feature is widely used 
today, because it constitutes an additional precaution 
against caries of the enamel. The recent introduction of 
the "seamless band" has been favorably received, especially 



Fig. 109 



Fig. 110 





Lukens' adjustable anchor band. All closing or continuous band. (After Barnes.) 

for the treatment of young patients. The advantage of a 
smooth lingual surface, as emphasized by Lukens, has 
prompted manufacturers to furnish seamless bands in such 
a variety of sizes that an accurate fit is readily obtained in 
most instances (Fig. 111). 

Fig. Ill 




Seamless ferrules, from which non-adjustable anchor bands can be constructed. 

The use of lingual extension wires, as advocated by 
Hawley, 1 for the buccal movement of teeth mesial to the 
first molars (Fig. 112), marks another step in advance. 



Proc. Amer. Soc. Orthodontists. 



THE ALIGNMENT WIRE 



159 



Pullen has recently suggested a modification of this principle 
by extending the screw-post (Fig. 113). 



Fig. 112 




Lingual extension wires. (After Hawley.) 
Fig. 113 




Showing continuation of the clamping bolt. (After Pullen.) 



THE ALIGNMENT WIRE 

According to Farrar, this element was used in the earliest 
times, when it was made of wood or strips of bamboo. 
Fauchard was probably the first to apply it in the shape of a 
metal strip, as shown in Fig. 95. Many of the mechanisms 
employed by Fox, Schange, Carabelli, Harris, Patrick, 
Farrar, and others embodied this element, when it was 
called the labial bow. In the design by Flagg (Fig. 97) it 
is seen in its simplest form. Farrar and Patrick employed 
it frequently, and developed many of it's attachments. 



160 PRINCIPAL ELEMENTS OF MODERN MECHANISMS 

Fig. 114 shows the attachment of spurs for preventing the 
slipping of ligatures, as advocated by Farrar. 1 This detail 
has recently been improved by Lourie, whose spur-cutting 
pliers for this purpose are excellent (Fig. 115). 

Angle's conclusive demonstrations regarding its wide 
range of applicability mark an epoch of no small moment 
in the treatment of malocclusion. Through his efforts we 
have learned that this simple wire establishes a line of 

Fig. 114 




Farrar's spur attachments to the alignment wire to prevent ligatures from 
slipping. 

alignment for the correction of arch form in advance of 
tooth movement; that it serves as a working basis for most 
of the individual tooth movements; that it may be utilized 
both for expansion and contraction of the dental arch; that 
it is the most efficient means, when properly manipulated, 
for arch movement; and finally, in the first stages of reten- 
tion, it serves as an excellent retaining device. 

The plain form, with threaded ends and nuts, answers 
every purpose in most cases, and Nos. 16 and 18 gauge 
represent the sizes in general use. Occasionally, in patients 
above ten years of age, the dental arch may be so contracted 

i Irregularities, 1888. 



THE ALIGNMENT WIRE 



161 



that lateral expansion in the region of the canines can be 
more readily accomplished by the use of a divided wire 
(Fig. 116), a design advocated by Bethel and Pullen. 



Fig. 115 




11 



Lourie spur-cutting pliers. 



162 PRINCIPAL ELEMENTS OF MODERN MECHANISMS 

An attachment of great value (Fig. 117) is that known as 
a tube hook. The tube fits the wire accurately, and is attached 

Fig. 116 




Divided alignment wire. (After Bethel and Pullen.) 

by means of solder in the region of the canines. This hook 
engages elastic bands, the uses of which are fully described in 
the chapters on Treatment. 

Fig. 117 



Intermaxillary tube hook. (After Angle.) 

LIGATURES AND ELASTICS 

The use of ligatures for tooth movement have been advo- 
cated from time immemorial. In the works of Fauchard, 
Bourdet, Jourdain, Linderer, etc., we find illustrations show- 
ing the manner of their application. Silk and linen threads 
were first employed for this purpose, as well as wires of 
iron, gold, and silver. 1 Angle, in connection with his appli- 

i Pfaff, Lehrbuch. 



MISCELLANEOUS ACCESSORIES 163 

ances of German silver, advocated the use of soft brass 
wire, ranging in size from 25 to 30 gauge. On the other hand, 
many operators now prefer the so-called silk grass line, 
recommended by Hawley. 1 This revival of the silk ligature 
is prompted largely by the present use of the noble metals, 
the rapid oxidation of which the brass wires promote; and 
by the tendency toward earlier treatment, when the force 
required is considerably less. 

The use of elastic rubber bands was advocated by Fox 
in 1814, who employed them in his practice. Lachaise, 
Tucker, Kingsley, and others continued their use to the 
present. While they are still largely employed for the 
various movements of individual teeth, their greatest value 
is in connection with arch movement. Case, Lourie, Baker, 
and Angle have recently developed this important detail 
of treatment, the importance of which can hardly be over- 
estimated. (See Chapters XVI and XVII.) 



MISCELLANEOUS ACCESSORIES 

Among the countless mechanisms that have been designed 
for the treatment of malocclusion, there have been very few, 
indeed, which have achieved survival. As intimated in 
Chapter VIII, only rarely are we obliged to use appliances 
other than those which can be constructed out of the elements 
enumerated above. And in these rare instances a very few 
additional elements will suffice, such as the lever, the skull 
cap for extramaxillary or occipital anchorage, the "Case 
contouring apparatus" for the bodily movement of teeth, 
etc. The use of these can best be described in the chapters 
on Treatment. 

1 Proc. Amer. Soc. Orthodontists, 



CHAPTER X 

PRINCIPLES OF APPLICATION 

In the application of every appliance we are forced to 
comply with certain fundamental mechanical requirements. 
The main points to be considered in this connection are: 
(a) The teeth to be moved (or the points of attack), (b) the 
forces employed (or the means by which movement is 
affected), and (c) the utilizable resistances (or anchorage 
of the means). Pullen 1 has defined anchorage as "the 
resistance selected as a base from which force is to be 
delivered for the movement of teeth." Ivorbitz 2 has very 
aptly stated that "The art and difficulty of orthodontic 
technique does not consist in the production of the acting 
forces, but of the advantageous utilization of the resistances 
present." Continuing he says: "In the masticating appa- 
ratus there is no fixed point from which we are able to act 
upon the individual teeth. The production of a move- 
ment always requires a point of anchorage; the forces 
employed act with the same power upon this point of 
anchorage as upon the point to be moved." 

FORMS OF ANCHORAGE 

The resistances utilized in the movement of teeth may 
be classified as follows: 

1 Operative Dentistry, Johnson. 2 Kursus der Orthodontie. 



FORMS OF ANCHORAGE 



165 



(a) As to method, into stationary and reciprocal. 

(b) As to source, into intramaxillary, intermaxillary, and 
extramaxillary. 

Stationary Anchorage. — This term is a merely relative 
one, since there is no absolutely fixed point in the dental 



Fig. 118 




Exemplifies stationary and reciprocal anchorage. 



arches. It may be described as a rigid resistance at "the 
point of departure," which may be due to the greater size 
and more abundant osseous support of the tooth utilized, 
to the manner of attachment of the appliance, or to the 
direction of the force employed. 

The appliance shown in Fig. 118 is intended to effect a 



166 PRINCIPLES OF APPLICATION 

mesial movement of the first bicuspid. This is accomplished 
by the use of a ligature attached to the alignment wire. 
The latter is anchored to the molar by means of an anchor 
band. If the nut on the wire is brought to bear upon the 
mesial end of the tube, the molar exemplifies stationary 
anchorage. Besides being larger, and offering greater resist- 
ance than the first bicuspid, it has the additional support 
of the second molar. The cuspid has not yet erupted, 
and hence the resistance mesial to the first bicuspid will 
yield. On the other hand, if the crown of the first bicuspid 
were inclined distally, and the first molar were unsup- 
ported by the second, the tendency for a distal movement 
of the first molar might readily assert itself. 

Reciprocal Anchorage. — A further study of the case reveals 
a labio version of the central incisors. The aim will be to 
move these lingually, which can easily be accomplished if 
the nut is released at the mesial end of the tube. By so 
doing, the alignment wire will glide distally within the tube 
until it bears upon the labial surfaces of the incisors at the 
points a a. The load imposed by the tension of the ligature 
from the bicuspid is now shared by the incisors, whose 
combined resistance is less than that of the molars. Hence 
we no longer have stationary anchorage; the incisors, 
like the bicuspid, will yield under this stress. We term 
this reciprocal anchorage, by which means the force is 
utilized at both a the point of attack" and "the point of 
departure." 

" In reciprocal anchorage the reciprocity of the resistance 
points is never quite perfect. This is due to the diversity 
of the resistances and to the variety of the deviations." 
(Korbitz.) 

If we release the nut prior to ligating the bicuspid, and 



FORMS OF ANCHORAGE 



167 



then subsequently tighten it, we can utilize both forms 
simultaneously. Indeed, this is the aim in most instances. 
The use of stationary anchorage per se is very limited, and 
rarely as satisfactory as the reciprocal form. Furthermore, 
if the anchor teeth are not carefully guarded, they rarely 
remain stationary. 

Intramaxillary Anchorage. — Many of the required tooth 
movements can readily be performed by the use of anchor 
bands and the alignment wire in combination with ligatures. 

Fig. 119 






Reciprocal anchorage. 

Previous to its insertion within the buccal tubes, it is bent 
to that ideal form we wish ultimately to establish. The teeth 
in each lateral half are then forced into normal alignment 
by ligation, and by the alternate and simultaneous use of 
stationary and reciprocal anchorage. Occasionally we seek 
the necessary resistance on the opposite side of the dental 
arch, as shown in Fig. 119. The two upper cuspids being 
similarly malposed, we resort to the most direct method of 
the jack-screw. This is a good example of reciprocal anchor- 
age, resulting in the simultaneous movement of the cuspids. 



168 PRINCIPLES OF APPLICATION 

In all cases where the resistances selected are in the same 
dental arch as the teeth to be moved the term intramaxillary 
anchorage is applied. 

Intermaxillary Anchorage. — There are many forms of mal- 
occlusion which cannot be so readily disposed of, and for 
which we are forced to seek anchorage in the opposing jaw. 
Whenever we employ an anchorage thus located, we term 
it intermaxillary anchorage. This is also used in both the 
stationary and reciprocal forms. 

Fig. 120 



*• 7*1 



Direct intermaxillary anchorage. (After Angle.) 

In the case shown in Fig. 120 we observe a lingual per- 
version of the right upper cuspid. After removing the 
superimposed gum tissue and providing an attachment to 
the cuspid, we can force its eruption by means of a small 
elastic-rubber ring anchored to the lower bicuspid and 
cuspid. This constitutes the simplest and most direct form 
of intermaxillary anchorage after the manner indicated by 
Angle 1 in 1891. 

Fig. 121 shows a similar case complicated by a mesio- 
version of the right upper bicuspids and molars, and linguo- 
version of the permanent canine due to prolonged retention 

1 Dental Cosmos, September, 1891. 



FORMS OF ANCHORAGE 



169 



of its temporary predecessor. Hence the first step in the 
treatment is a distal movement of bicuspids and molars. 
This cannot be accomplished in the ordinary manner; the 
resistance offered by the incisors to the mesial is not equal 
to the task. Nor would an anchorage point on the opposite 
side of the same dental arch be of any value. We therefore 
search for the necessary resistance in the opposing arch, as 
suggested by Lourie 1 (Fig. 122). In this instance we secure 

Fig. 121 




Case requiring the use of intermaxillary anchorage for its correction. 

stationary anchorage in the lower by ligating several of the 
anterior teeth to the alignment arch and so adjusting the 
nut that it comes into contact with the mesial ends of the 
buccal tube. In the upper arch the nut is adjusted so that 
the alignment wire does not touch the labial and buccal 
surfaces of the teeth mesial to the molars. Hence the 



Amer. Soc. Orthodontists, 1902, 



170 PRINCIPLES OF APPLICATION 

combined resistances of the lower teeth, by means of the 
elastic bands, is thrown against the upper molar, forcing it 
distally. After sufficient distal movement of the molars has 
been gained, the attachment is changed to the bicuspids and 
these in turn moved distally. 

Fig 122 




Mechanism employed for intermaxillary anchorage. 

Recent advances in the use of intermaxillary anchorage 
have so enlarged its field of application that it has become 
the most valuable of all. The wide range of its applicability 
constitutes one of the most important steps in orthodontic 
progress; without it, the correction of arch malrelation would 
be extremely difficult, if not impossible. (See Chapters XVI 
and XVII.) 

Extramaxillary Anchorage. — Prior to the perfection of 
intermaxillary anchorage, many of the pronounced forms of 
malocclusion (such as mesioclusion and distoclusion) were 
treated by means of occipital anchorage. This was obtained 
by the wearing of a cap, or network with frame, adjusted 
to the back of the head, to which the chin cap or cross-bar 
was attached by means of heavy elastics (Figs. 123 and 
124). This form constitutes the best type of stationary 
anchorage, but unfortunately is under the patient's control. 
It is extremely annoying and conspicuous, and is now 






FORMS OF ANCHORAGE 

Fig. 123 



17 




Extramaxillary anchorage. (After Angle.) 
Fig. 124 




Extramaxillary anchorage. (After Angle.) 



172 PRINCIPLES OF APPLICATION 

rarely employed, owing to the recent advances in the use of 
intermaxillary anchorage. 

To the beginner, a discussion of the problems of anchor- 
age may seem as a mass of trivial reflections ; in reality, they 
constitute some of the hardest lessons to be learned. A 
mastery of these principles enables one to accomplish truly 
remarkable results with the very simplest mechanisms. 
Ignorance, on the other hand, yields consequences quite 
unexpected. An exhaustive study of the principles of 
anchorage, theoretical as well as practical, is therefore 
advisable. "They must be transfused into our flesh and 
blood, so that we may employ them automatically in our 
practice; just as we use the multiplication table in calcu- 
lation." (Korbitz.) 



CHAPTER XI 

DETAILS OF APPLICATION 

In preceding chapters many of the preliminaries for 
treatment were described. The next step is a detailed 
consideration of the plan of treatment, which should always 
be carefully worked out beforehand and in accordance with 
a definite routine. An operator must always be mindful 
of the many necessary details, and then firmly resolve to 
carry them out. 

BANDS 

The Anchor Band. — As intimated in Chapter X, a compli- 
ance with fundamental mechanical principles is imperative; 
hence the anchorage of the appliance should receive first 
consideration. In view of the fact that this is provided 
in most instances by the use of anchor bands, the details 
of their application are important. A very limited experi- 
ence readily emphasizes the fact that the first permanent 
molars are preferable to any other teeth in the arch for 
purposes of anchorage, owing to their large size and early 
calcification. Only in rare instances, owing to the absence 
of these teeth, are we compelled to utilize the second molars 
or bicuspids. 

After a decision has been reached as to the teeth to be 
utilized, the selection of an anchor band should be made. 
The author prefers an all-closing adjustable band, as shown 
in Fig. 110. Prior to its insertion it is contoured to approxi- 



174 DETAILS OF APPLICATION 

mate the form of the tooth upon which it is to be placed. 
It is frequently necessary to bend the screw-post on the 
lingual side, so that it closely embraces the tooth to the 
mesial. In case the second molars have erupted, and lateral 
expansion in this region is indicated, it may be advisable 
to place the band so that the bolt will point in a distal 
direction (compare Fig. 118). The protrusion of the screw- 
post into the oral space toward the tongue is never necessary 
if care is exercised in the adjustment. The mesial portion 
of the band should always be forced well up under the gum, 

Fig. 125 




Shows correct adaptation of anchor band to a molar. (After Angle.) 

and the distal slightly burnished over the distal marginal 
ridge to prevent displacement. 1 The tubes being soldered 
parallel with the borders of the band, this manner of adjust- 
ment will effect a proper occlusogingival alignment of the 
buccal tubes (Fig. 125). 

In very young patients (owing to a superabundance of 
gum tissue), and in cases of infraversion of the molars, it is 
best to use a seamless band. This is first adjusted without 
a tube, which latter is soldered on subsequently. 

All anchor bands should be of the proper size and accu- 
rately adjusted, and they should invariably be set with 

1 Angle, Malocclusion of the Teeth, 



BANDS 175 

cement. Cementation is always deferred until the second 
sitting, when the anchor teeth are again thoroughly cleansed 
with pumice and washed with alcohol, the saliva excluded 
by means of cotton rolls, and dryness maintained. 

The Plain Band. — The next step is to determine which 
teeth will require plain bands, and the various attachments 
for each band. The form of a tooth and its required move- 
ments will usually settle this. For most patients the adap- 
tation of the band metal is readily accomplished; but if 
firmly established contact points interfere with the adapta- 
tion, it is best to separate the teeth by means of a separator, 
or by the insertion of tape, for twenty-four hours. 

Fig. 126 




Double end burnisher (Woodson No. 3). 

After all the bands in one arch are thus prepared, they 
are laid to one side, and the anchor bands of that arch are 
adjusted. The patient is now dismissed, and during the 
interim prior to a subsequent visit the plain bands are 
constructed and finished. Upon the patient's return each 
band so constructed is placed upon the tooth for which "it was 
prepared. This can usually be effected with the fingers and 
one or two gentle blows from a mallet on a band driver. A 
more accurate fit can now be obtained by frequent burnishing 
with the double end instrument shown in Fig. 126. 

The bands are now removed without changing their form, 
and placed upon the operating table. Their inner surfaces 
are cleansed with alcohol, and the operating table prepared 



176 DETAILS OF APPLICATION 

for cementing them into place. The teeth to be banded are 
again thoroughly cleaned with powdered pumice, and a 
polishing point in the dental engine, after which they are 
isolated with a napkin or cotton roll. After washing the 
tooth with alcohol and drying with compressed air, the 
inner surface of the band is lined with a coat of cement and 
placed in position. The final adjustment is best accomplished 
with a band driver and mallet and the burnisher. The 
surplus cement is now removed and the exclusion of moisture 
continued until the remaining cement has thoroughly 
hardened. 

In cases where there is considerable crowding, and where 
two or more adjoining teeth all require bands, the double 
thickness of metal in each interproximal space will occa- 
sionally interfere with their ready insertion. A good plan 
in such instances is to adjust the bands without cement, 
and to dismiss the patient for twenty-four hours, after which 
sufficient separation will have been gained. 

All bands should fit accurately, and all attachments 
should be well soldered and highly polished. 

THE ALIGNMENT WIRE 

Following the adjustment of the plain and anchor bands, 
an alignment wire is adapted to complete the appliance. 
The sizes in common use are of 16 and 18 gauge, and they 
are furnished sufficiently long for all cases. They are 
shaped to an ideal form by the manufacturer, and must, 
therefore, be bent to conform to the requirements of a 
given case and cut to exact length. This preliminary adap- 
tation can partly be executed on the model, and partly by 
trial insertions in the mouth. 



THE ALIGNMENT WIRE 



111 



During the adjustment of the anchor bands the subse- 
quent insertion of the wire within the tubes must be kept 



Fig. 127 




<ww-' ' .". . ' . . iTTT ^r?r^Tr^A^Wiii 



Properly shaped alignment -wire. 
Fig. 128 




Improperly shaped alignment wire. 

in mind. In other words, the two buccal tubes on opposite 
sides of the dental arch should occupy a common plane, 
12 



178 DETAILS OF APPLICATION 

with the mesial ends of the tubes pointing slightly toward 
the gingival. Viewed in their buccal, or horizontal, aspects, 
the threaded ends of the wire appear as in Fig. 127. The 
careless adjustment of the buccal tubes and of the align- 
ment wire will result in the improperly shaped appliance 
shown in Fig. 128. 1 

Occasionally, it is permissible to bend the wire mesial to 
the nuts (Fig. 129), or in the region of the cuspids (Fig. 
130), to effect the proper alignment in the incisal area. In 

Fig. 129 




Bending the wire immediately mesial to the buccal tubes to gain correct 
alignment. 



Fig. 130 
BBBEEBBEB iggfflfflQiEEBEgBgS 




Bending the wire in the region of the cuspids. 

cases where intermaxillary anchorage is employed, it is 
best to avoid this, and to procure correct alignment by 
resoldering the anchor tubes. 

Viewed from an occlusal aspect, the free ends of the 
alignment wire must again receive careful attention. A 
proper relation to the dental arch can readily be secured by 
bending with a pair of clasp pliers, and by repeated trials 
of one end within a tube, as shown in Figs. 131 and 132. 
By means of the pliers we can produce an expansion or con- 

1 Korbitz, Kursus der Orthodontic 



THE ALIGNMENT WIRE 



179 



traction of the wire, in whole or in part, depending on their 
position and manner of application. 1 (Figs. 133 and 134.) 



Fig. 131 




Fig. 132 




Shows the adaptation of the ends of the wire. 

After a correct adaptation has been effected, the wire is 
inserted in both tubes and allowed to remain in a merely 
passive state, our first aim being to accustom the patient 
to its presence within the mouth. In cases where it must 
encircle an extreme labioversion of one or more teeth it may 
be necessary to give it a decidedly abnormal form, to avoid 



Korbitz, Kursus der Orthodontic 



180 DETAILS OF APPLICATION 

Fig. 133 




Producing an expanding action over its entire length. 



Fig. 134 




Restricting the expanding action; by reversing the beaks of the pliers a contracting 
action can be obtained. 






LIGATURES AND ELASTICS 181 

undue prominence. Only subsequently, after considerable 
movement of the adjoining teeth, do we give it that ideal 
form we wish to establish. 



LIGATURES AND ELASTICS 

Many movements of the teeth are accomplished by the 
use of ligatures. As previously stated, the silk grass line 
(which comes in three sizes, heavy, medium, and light) 
is widely used for this purpose. Occasionally, owing to the 
position and form of a tooth (particularly lower cuspids), 
a wire ligature is more effective. These are usually from 25 
to 30 gauge thick, and made of soft, annealed brass. 

All ligatures should be of generous length, to permit 
of a firm grasp while applying them. Wire ligatures are 
tightened by twisting, and silk ligatures by tying in a surgical 
knot. The more important ways of using a ligature are 
shown in Fig. 102. Owing to the absorption of moisture, 
the silk ligature continues in its tension for a considerable 
period, often a week or more. The spring of the alignment 
wire also aids in prolonging their action. Wire ligatures 
can be tightened by additional twisting, thus obviating 
their frequent renewal. 

Elastic rubber bands are widely used in present-day 
practice, particularly in intermaxillary anchorage. Occa- 
sionally, they are of value in intramaxillary anchorage, e. g., 
in rotation of a bicuspid (Fig. 163). A liberal supply should 
always be kept in stock, varying in size from an "election 
ring" to those made from f-inch pure rubber tubing. The 
former are used principally in the treatment of mesioclusion 
and distoclusion, for reenforcement of anchorage, and for 
reduction of extreme labioversion of the upper incisors. The 



182 DETAILS OF APPLICATION 

small sizes are employed for direct intermaxillary anchorage 
for the correction of infraversion (Fig. 120). In the latter 
method they are usually limited to the hours of sleep, while 
in the former they can be worn constantly. The patient 
should be taught the manner of their application, and 
provided with a sufficient number for frequent renewal. 
Owing to the fact that their action is constant, they require 
careful supervision to prevent undue displacement of the 
anchor teeth, as well as the teeth to be moved. 






CHAPTER XII 

PRINCIPLES OF RETENTION 

TISSUE CHANGES CAUSED BY TOOTH MOVEMENT 

During tooth movement a number of very important 
changes are produced in the tissues of attachment. All 
authorities are agreed that the immediate result of the 
application of force is a compression of the fibers of the 
pericementum on the side toward which a tooth is moved, 
and a stretching of those on the opposite side. In the first 
stages following pressure a feeling of pain is frequently 
induced, due to mechanical irritation of the nerves in this 
membrane. This speedily ceases if the pressure is constant, 
and is followed by hyperemia. Later, an absorption of 
the resisting alveolar plates is produced by osteoclasts, 
or "bone-destroying" cells, which make their appearance. 
The mechanism of this process of destruction is not yet 
fully understood, though many theories have been advanced 
as to the probable cause of the molecular dissolution of 
the osseous support. 

Some observers have maintained that in many instances 
a bending of the alveolar plates (and even fracture) takes 
place; and occasionally an opening of the maxillary suture 
has been induced by rapid lateral expansion of the upper 
arch for young patients. 1 

The manifold functions of the pericementum exercise an 
exceedingly favorable influence during these serious stages 

1 See Proc. Amer. Soc. Orthodontists, 1911. 



184 PRINCIPLES OF RETENTION 

of destruction and the repair which follows. The deposition 
of bone on the side from which a tooth is moved is controlled 
by osteoblasts, or "bone-building" cells, but is far less rapid 
than absorption and tooth movement. 



DEFINITION 

Owing to the fact, then, that the osseous support of the 
teeth is more or less destroyed by the process of absorption, 
and the subsequent formation of new bone considerably 
prolonged, it leaves them suspended by their soft, peri- 
cemental attachments in greatly enlarged sockets. The 
length of this period of inadequate maintenance varies in 
different individuals, during which time the fibers of the 
pericementum tend to force the teeth back to their former 
abnormal positions. This necessitates the application of 
mechanisms for the purpose of retaining the teeth in their 
new positions until this tendency has subsided and socket 
repair has been completed. Retention may, therefore, be 
defined "as the maintenance of sufficient antagonism to the 
forces tending to cause the return of a corrected malocclusion 
to its original condition, to insure permanency of the normal 
relationships of occlusion which have been established." 
(Pullen. 1 ) 

Other factors besides that of age which may influence the 
time required and the ultimate success of retention, are the 
general and oral health of the individual, the kind and extent 
of movement accomplished, the detection and removal of 
causative factors, and the occlusal contact established. 
Pathological conditions of the pericementum militate 

* Items of Interest, April, 1907. 



DEFINITION 185 

against successful retention. Nasal obstruction, pernicious 
habits, and other causative factors, when present, must 
always be removed or corrected. And Walkhoff 1 long ago 
pointed out that "the placing of the teeth into normal 
articulation (occlusion) is a fundamental postulate in the 
treatment of malocclusion, insuring permanent results." 
Or, as Angle 2 puts it, "It cannot be too strongly insisted 
upon that the permanency of the teeth in their new T positions 
cannot be hoped for, regardless of the length of time the 
retaining devices have been worn, unless such occlusion 
has been established as will enable the inclined planes of 
the cusps to ultimately act in perfect harmony for mutual 
support." 

In designing a retaining appliance it is imperative that 
we study the probable movement of each individual tooth 
in its tendency toward its original position. This can 
only be done by comparing the original models with the 
ideal that has been established. In the words of Angle, the 
underlying principle of design should be "to antagonize the 
movement of the teeth only in the direction of their tendencies. 
Very slight antagonism is required, but its exercise must be 
constant." 

The time required for successful retention varies from 
three weeks to three years, and in rare instances it is neces- 
sary to resort to permanent retention. All uncemented 
contact points of a retention appliance should be reduced 
to the minimum, to prevent caries of the enamel, and all 
bands securely cemented to the teeth to which they are 
attached. 

1 Die Unregelmassigkeiten in den Zahnstellungen, Leipzig, 1891, p. 37. 

2 Malocclusion of the Teeth, 1907, p. 263. 



186 PRINCIPLES OF RETENTION 



MAINTENANCE OF TOOTH POSITION 

Innumerable mechanisms for retention have been sug- 
gested, dating back to the ferrule, or plain band, used by 
Disarabode in 1823. The appliances in use today are the 
result of countless efforts, and they have passed through 
many modifications. There can no longer be any doubt, 
however, that plain bands and their many combinations, 
as suggested by Farrar, Guilford, Case, Angle, and others, 
constitute the best and most widely used designs. 




Plain band with two spurs for maintaining a corrected torsoversion. (After Angle.) 

Fig. 135 shows a band (F) upon an upper lateral which 
has been rotated. After accurate adaptation the band is 
removed and one or two spurs (6r) are attached with solder, 
as may be indicated. The spurs should be of sufficient 
length to engage the adjoining teeth (though not too long) 
after which the appliance is polished and set with cement. 
In most cases of malocclusion the treatment involves the 
movement of several adjoining teeth, hence the retainer 
should be planned so as to include as many as possible, 
thereby gaining simplicity of design. Figs. 136, 137, and 
138 illustrate designs by Angle in which this principle has 
been carried out. They consist of plain bands united by 



MAINTENANCE OF ARCH FORM 



187 



connecting wires, the dotted lines indicating the preexisting 
malocclusions. 



Fig. 136 



Fig. 137 





Fig. 138 




Showing advantageous combinations of the plain band with connecting wires. 
(After Angle.) 



MAINTENANCE OF ARCH FORM 

The treatment of malocclusion invariably implies the cor- 
rection of arch form, and in all cases where this is extensive 
the posterior teeth are necessarily involved. Not infrequently 
this includes the buccal movement of bicuspids and molars, 
whose subsequent lingual tendencies must therefore be 
counteracted. In 1873 Farrar 1 introduced vulcanite plates 
for this purpose, which have been in use ever since (Fig. 139). 
Such plates have passed through a variety of designs, and many 
convenient attachments to them have been recommended. 
But as Guilford 2 says : " Their use is open to certain objections. 
All plates, used either for correction or retention, must be re- 
moved at frequent intervals for cleansing. The very necessity 
for their removal affords opportunity for the patient to 



1 Irregularities, i, 366. 

2 Orthodontia, 4th edition, p. 129. 



188 



PRINCIPLES OF RETENTION 



remove them at other times, and possibly forget or wilfully 
neglect to reinsert them for a longer or shorter period, thus 
causing delay in the reparative process." 



Fig. 139 




Vulcanite plate advocated for maintenance of arch form in the posterior teeth. 

Fig. 140 




Retention apparatus embracing the entire arch. 

Owing to their unreliability, they have therefore been 
largely discarded and replaced by non-removable appliances. 
For maintaining the corrected arch form the lingual extension 
wires advocated by Case, Watson, and Lourie have found 
general favor. Fig. 140 shows the author's modification, 
and consists of two molar bands and an 18- or 20-gauge 



MAINTENANCE OF ARCH RELATION 



189 



iridioplatinum wire constructed in three sections. Section 
a accurately follows the arc described by the six anterior 
teeth, and its ends are extended into the interproximal 
spaces distal to the cuspids. Sections b and c connect this 
with the anchor bands. The bands on the cuspids are 
provided with spurs to prevent displacement of the wire, 
but are not attached to it. These bands are cemented into 
place prior to inserting the remaining apparatus. This 
appliance permits of many modifications, which will be 
referred to in the chapters on Treatment. 



MAINTENANCE OF ARCH RELATION 

The correction of arch malrelation (mesio-and distoclusion), 
without resorting to the extraction of permanent teeth, prob- 
ably dates back to Catalan's planum inclination and Kingsley's 
bite-plate for "jumping the bite." Recent advances in the 



Fig. 141 



Fig. 142 





Antagonizing spur retainers. (After Angle.) 

treatment of these deviations necessitated improvements in 
the methods of retention. The principle of this inclined plane 
in the form of antagonizing spurs (Figs. 141 and 142) has been 
advocated by Angle for this purpose. This method imposes 
a severe strain upon the anchor teeth, and frequently results 
in their displacement. Many operators have sought to 
avoid this, and now place chief reliance in a continuation of 



190 



PRINCIPLES OF RETENTION 



the intermaxillary anchorage used in correction, though in a 
weakened and modified form. 1 

Fig. 143 shows an appliance designed for this purpose in a 
case of bilateral distoclusion. Each arch is provided with 
an appliance for the maintenance of the corrected arch 
form. On the upper, canine bands with delicate hooks of 
20-gauge iridioplatinum wire are provided for the attach- 
ment of light elastic rings. The latter are stretched to 
hooks on the buccal surfaces of the lower molar bands, and 

Fig. 143 




Showing the continuation of the intermaxillary elastic for the maintenance of 
a corrected distoclusion. (After Pullen.) 

are worn at night. During the last stages of retention the 
elastics are worn on alternate nights. 

In mesioclusions the attachments are placed on the lower 
cuspid and upper molar bands, and the stretching of the 
elastics is reversed. In unilateral deviations the elastic is 
worn only on the side originally abnormal. For further 
designs and their modification the reader is referred to 
the chapters on Treatment. 



See Watson, Proc. Amer. Soc. Orthodontists, 1908; Rogers, Ibid., 1909 and 1910. 



PART II 
THE METHODS OF TREATMENT 



CHAPTER XIII 

TREATMENT OF MALPOSITION OF THE TEETH 

Technically, every treatment of malocclusion embraces 
two or more of the following rudimentary principles: The 
correction of (a) tooth position, (b) arch form, (c) arch 
relation, and, conjointly, of jaw and face deformity. It has 
already been pointed out that a tooth may occupy any one 
of nine possible malpositions and their various combina- 
tions, and we now approach the technical details of their 
treatment. 

LABIOVERSION AND BUCCOVERSION 

The term labioversion is used to denote labially malposed 
incisors and cuspids, and buccoversion for buccal malpositions 
of the bicuspids and molars. These two terms are here 
grouped together because their treatment is similar, imply- 
ing a lingual (or inward) movement in each instance. For- 
merly, the use of special apparatus for the treatment of 
these deviations was considered a necessity (Figs. 144 and 
145); but it rarely happens that only one tooth is in mal- 



192 TREATMENT OF MALPOSITION OF THE TEETH 

occlusion. A careful study of occlusal relation usually leads 
to the discovery of malposition in adjoining and opposing 
teeth. Furthermore, the wide range of applicability of the. 
alignment wire and its accessories (by utilizing the various 
forms of anchorage) has rendered it possible to carry out 

Fig. 144 




Fig. 145 




Discarded methods for the correction of labioversion. 



most lingual movements without resorting to the use of 
special mechanisms. In fact, it is our constant aim to avoid 
special appliances, and to design new uses for those already 
employed. 

Happily, in most instances the teeth immediately mesial 
and distal to a labioversion are in linguo version. The 



LABIOVERSION AND BUCCOVERSION 193 

undue prominence of a labioversion may thus be advan- 
tageous, permitting the use of reciprocal anchorage. In 
adjusting the alignment wire for a case as shown in Fig. 146, 
it invariably fails to come in contact with the labial and 
buccal eminences of the teeth adjoining the cuspid. The 
labial movements of the lateral incisor and first bicuspid are 
accomplished by ligation to the wire, which is so adjusted 
as to come in contact with the labial ridge of the cuspid. 
By previously releasing the nut mesial to the buccal tube, it 
will be permitted to rest passively, and glide "inwardly," 
within the tube. The force exerted upon the lateral and 
bicuspid will be equally delivered upon the cuspid, producing 
a lingual movement in the latter. In attempting a move- 
ment of this kind, it should always be remembered that the 
necessary mesiodistal spaces for each tooth must be within 
the range of possibility. Considerable expansion of the 
dental arch is, therefore, frequently indicated, and clearly 
impossible if we employ a mechanism as shown in Fig. 144. 
The extraction of the first bicuspid for the accommodation 
of the cuspid, as shown in Fig. 145, is rarely if ever considered 
justifiable. 

Frequently, in crowded arches, the complete labial move- 
ment of the incisor and buccal movement of the bicuspid 
will not progress uniformly with the final adjustment of the 
cuspid, in which event we resort to the use of the rubber 
wedge (Fig. 147). The ligatures employed for the lateral 
and bicuspid, and the nut in front of the buccal tube, will 
provide stationary anchorage for the alignment wire, and 
thus afford the necessary resistance for the rubber. This is 
a very effective method for accomplishing lingual movements 
in cuspids, and through reciprocal action, labial movements 
of the adjoining teeth. A further utilization of this principle 
13 



194 TREATMENT OF MALPOSITION OF THE TEETH 

is shown in Fig. 148, for the correction of buccoversion of 
a second bicuspid and linguo version of a first bicuspid. 
The use of intermaxillary anchorage for the reduction of 
labioversion of the incisors in neutroclusion and distoclusion 
is described in subsequent chapters. 



Fig. 146 



Fig. 147 





Illustrates the use of reciprocal 
anchorage. 



Fig. 



Intensifying the pressure by means of the 

rubber wedge. 
148 




Advantageous utilization of reciprocal anchorage. 



Buccoversion of the molars is comparatively rare, and can, 
in most instances, be corrected by utilizing the spring 
temper of the alignment wire. By reversing the beaks of the 
pliers shown in Figs. 133 and 134, a contraction of the arch 
can be effected. 



LINGUOVERSION 195 



LINGUOVERSION 

This is a very common form of malposition, and the 
methods for its correction are numerous. One of the most 
powerful and satisfactory methods at our command is 
illustrated in Fig. 119. However, such instances are ex- 
tremely rare; linguo version is usually associated with labio- 
version of the adjoining teeth. Hence the alignment wire, 
by means of which we can accomplish all of the various 
movements, is to be preferred. 

As previously intimated, outward movements can readily 
be accomplished simultaneously with lingual or inward move- 
ments. The tension of a ligature employed for this purpose 
may likewise be increased if used in combination with the 
rubber wedge, as shown in Fig. 149. The reciprocal form 

Fig. 149 




Correction of linguo version. 

of anchorage should be employed whenever possible, for if it 
is neglected at the outset the difficulties occasioned by the 
adjoining labio- or buccoversions are increased. For example, 
let us assume that we neglect such an opportunity in the 
case shown in Fig. 150, and attempt to correct the linguo- 
version of the lateral incisors by utilizing the stationary 
anchorage of the molars. Now, a more detailed considera- 
tion of the case reveals the labioversion of the central 
incisors. But suppose we had completed the labial move- 



196 TREATMENT OF MALPOSITION OF THE TEETH 

ments of the laterals before realizing this fact; it at once 
becomes clear that the reduction of the labioversion of the 
centrals has become more difficult. Hence, if we are mind- 
ful of our advantages in advance, we can, by releasing the 
nuts mesial to the buccal tubes (thus allowing the alignment 
wire to rest upon the labial surfaces of the centrals), utilize 
reciprocal anchorage. 

Fig. 150 




Reciprocal anchorage for correction of linguoversion and labioversion. 

The buccal movement of molars is readily accomplished 
by utilizing the spring temper of the alignment wire (see 
Figs. 133 and 134). Such movements may be required on 
one side of either the upper or lower, or on both sides, and 
in both upper and lower arches simultaneously. But in 
either event the movement must be carefully guarded to 
prevent undue speed. Should it proceed too rapidly, it 
may be counteracted by reducing the expansion pressure 



L1NGU0VERSI0N 197 

of the wire by reversing the pliers, and by resorting to direct 
intermaxillary anchorage, as shown in Fig. 151. 

To prevent undue tipping of the incisors during labial 
movements, it frequently becomes necessary to adapt the 
alignment wire close to the gingival line, as shown in Fig. 
153. In extreme cases a modification of the Case contouring 
apparatus, as suggested by Korbitz, 1 can be employed (Fig. 
154). Again, unfavorable tipping may assert itself in rapid 

Fig. 151 Fig. 152 





Intermaxillary anchorage used as an Increased stretch of the rubber in corn- 

auxiliary in case of unexpected displace- bination with alignment wires for the 
ment of the anchor teeth. correction of linguoversion and buccover- 

sion of molars. (After Reoch.) 

buccal movements of the molars, and thus cause extremely 
undesirable difficulties of occlusion. To avoid the use of 
the direct intermaxillary anchorage already referred to 
(which is annoying to the patient), and in anticipation of 
such undesirable movements, we may employ the square 
tubing on the molar bands, as suggested by Kemple. 2 Vari- 
ous other forms of molar anchorage for this purpose have 

1 Kursus der Orthodontie. 2 Proc. Amer. Soc. Orthodontists, 1909. 



198 TREATMENT OF MALPOSITION OF THE TEETH 

been suggested by Barnes, Hawley, and Ottolengui. 1 These 
latter forms may all be advantageously employed for the 

Fig. 153 




High adjustment of the alignment wire to prevent tipping of the incisors 
during labial movements. 

Fig. 154 




Korbitz's modification of Case's contouring apparatus. 

bodily buccal movement of the molars, thereby inducing 
desirable lateral development in the osseous structures, 
whenever that is indicated. 



DISTOVERSION 



The correction of a distoversion implies a "mesial move- 
ment within the line of the arch. One of the simplest 



Proc. Amer, Soc. Orthodontists, 1909. 






DISTOVERSION 



199 



instances of this kind is shown in Fig. 155, illustrating the 
method of correcting two upper centrals in distoversion as 
a result of an abnormal frenum labium. The silk ligature, 
owing to its prolonged tension in a moist environment, is 
admirably adapted for this purpose. Occasionally, it may 
be advantageous to construct a plain band for each incisor, 

Fig. 155 




For mesial movement of the central incisors. 
Fig. 156 




For mesial movement of the central incisors. (After Lukens.) 



with a labial spur (Fig. 156) for the attachment of a wire 
ligature, which is applied in the form of a figure eight. 
Such ligatures should be about one foot long, permitting a 
firm grasp with the hands while twisting their knots. The 
silk ligature already referred to may occasionally be carried 
beyond the centrals and include the laterals and cuspids. 



200 TREATMENT OF MALPOSITION OF THE TEETH 

Small spaces between the six anterior teeth in either jaw 
may readily be closed in this manner. The skilful use of 
the silk ligature is an important detail of treatment, even 
though it be difficult to master. 

In all cases where the separation between the centrals is 
very marked the use of a ligature is contraindicated. Its 
hinge-like attachment favors tipping instead of bodily 
movement. The latter can be accomplished by substituting 
the screw bolt anchored to bands by means of tubes, as 
shown in Fig. 157. 

Fig. 157 





j^-^T^^^B 




\ 




hi 


9l 


M • dNI 



For bodily mesial movement of the central incisors. (After Lukens.) 



The mesial movement of bicuspids may also be affected 
by ligatures in combination with notches on the arch (Fig. 
118). After all mesial movements anterior to the molars 
have been accomplished, during which the anchorage was 
provided by these teeth, the nuts may be released and the 
molars moved mesially if indicated. This is usually best 
accomplished by means of intermaxillary anchorage (Fig. 122 
for lowers, and Fig. 230 for uppers). 



MESIOVERSION 



201 



MESIOVERSION 

Though rarely met with in incisors, and only occasionally 
in cuspids, it is frequently found affecting bicuspids and 
molars. When it extends to the anchor teeth the difficulties 
of treatment are considerably increased. A single anterior 
tooth, such as a central or lateral, may usually be moved 
distally by ligation to a wire provided with a spur in a 
suitable location. Cuspids only slightly in mesioversion 
(which are almost invariably associated with linguoversion 
of the lateral incisors) are readily reduced by means of the 
rubber wedge (Fig. 147) . The rubber must, in such instances, 
be applied toward the mesiolabial angle. In extreme mesio- 
version of a cuspid the latter method would prove inade- 
quate, hence we are occasionally compelled to employ the 
traction screw (Figs. 158 and 159). 

Fig. 159 





Angle's method for effecting a distal movement of the canine. 



Not infrequently, owing to a premature loss of deciduous 
cuspids and first molars, the first bicuspids erupt mesial to 
normal. In all cases where other treatment is in progress 
during such a period, the author uses the method shown in 
Fig. 160. The illustration shows an arm extended from the 
alignment wire which is moved distally by means of a nut. 
The arm is made from an ordinary tube hook and prevented 



202 TREATMENT OF MALPOSITION OF THE TEETH 

from dropping occlusally, or being forced gingivally, by 
flattening the alignment wire with a file along its lingual 
surface and subsequently adapting the tube to it. This 
appliance is also applicable in the correction of distoversion. 
Mesioversion of a first permanent molar may, in rare 
instances, be corrected by utilizing all of the anterior teeth 
for anchorage, e. g., where the second deciduous molar was 

Fig. 160 




Author's method for correcting mesioversions and distoversions of bicuspids. 

lost prematurely. The combined resistance of the anterior 
teeth, after secure ligation to the alignment wire, may thus 
be pitted against the first molar by turning distally the nut 
in front of the tube. Finally, the distal movement of the 
anchor teeth can be accomplished by use of intermaxillary 
anchorage — as in mesioclusion, and in cases of distoclusion — 
and in rare instances by means of extramaxillary anchorage. 
These are described in subsequent chapters. 



CHAPTER XIV 

TREATMENT OF MALPOSITION (Continued) 
TORSOVERSION 

This is a very common form of malposition, and its 
treatment dates back to Delabarre 1 (1815), who used a 
lever for its correction, and Linderer (1834) and Schange 
(1841), who accomplished the same end with the ligature. 
The lever was also employed by Linderer, and has recently 
been revived, in a somewhat modified form, by Angle. 2 
Its use is, however, rarely indicated, because it possesses a 
distinct disadvantage in that it causes an outward move- 
ment, as well as rotary action. 3 Furthermore, the mere 
fact that we rarely have to deal with malposition of only one 
tooth compels us to employ other mechanisms; hence the 
alignment wire, with its limitless possibilities, again merits 
our attention. 

On the other hand, the principle of the lever is still worthy 
of our consideration, especially in a restricted or localized 
sense. It is well known that a corrected torsoversion is 
hard to maintain in a normal relation, and it is in such 
instances that the modified lever plays an important role. 
The retainer of a torsoversion frequently embodies a spur 
of wire, which can be pressed into service should a tendency 

1 Pfaff, Lehrbuch der Orthodontie. 

2 Proc. Int. Med. Congress, Washington, 1887. 

3 See Korbitz, Kursus der Orthodontie. 



204 



TREATMENT OF MALPOSITION 



toward a former malposition assert itself. Fig. 161 shows an 
application of this principle during the retention period. 
Korbitz 1 has recently suggested a modification of it for the 
treatment of a simple torso version, provided the necessary 
space can be gained by the purely local action (Fig. 162). 
He maintains that the rubber elastic shown in the illustration 
exerts the necessary sideward, or separating, action. The 
tube attachment of the lever provides a hinge-joint, which 
permits the rotary movement. 



Fig. 161 



Fig. 162 






For effecting slight rotary movements. 



Hinge appliance for rotation. (After 
Korbitz.) 



The roots of bicuspids present oblong forms on cross- 
section, and offer considerable resistance to a rotary move- 
ment. It occasionally becomes necessary, therefore, to 
apply extreme measures to accomplish the desired results. 
Fig. 163 shows a case of this kind from the collection of Dr. 
Lukens, and exhibits the pushing action of a jack-screw 
on the buccal side, and the pulling action of a rubber ring 
on the lingual. 



See Korbitz, Kursus der Orthodontie. 



TORSOVERSION 



205 



In rare instances, the molars will require rotation, and, if 
confined to the anchor teeth, this can readily be accom- 
plished with the ends of the alignment arch (Figs. 131 and 
132). Should the second molar be in torsoversion, the 
draught of an elastic ring can be called into service after 
the manner suggested by Korbitz 1 (Fig. 164). 

Fig. 163 




Forcible correction of torsoversion of a bicuspid. (After Lukens.) 

The rotation of incisors, cuspids, and bicuspids can 
generally be affected by means of the ligature, and we now 
pass to the details of its application. Fig. 165 shows the 



Kursus cjer Orthodontie. 



206 



TREATMENT OF MALPOSITION 



application of a silk ligature for the correction of a simple 
torsoversion in an upper central incisor, the ligature being 
applied in the form of a loop. Fig. 166 shows the applica- 



Fig. 164 




Correction of torsoversion in the second molar. (After Korbitz.) 
Fig. 165 




The silk ligature applied for correction of torsoversion in an upper central. 
Fig. 166 




The silk ligature applied for reciprocal action in correcting lower centrals in 
torsoversion. (After Korbitz.) 

tion of a silk ligature to the lower central incisors. In all 
cases where the lower centrals are of sufficient length and 
of favorable form, this method will prove efficacious. 



TORSOVERSION 



207 



Both upper and lower cuspids, owing to their unfavorable 
form, usually require the use of bands and spurs to prevent 
the ligatures from slipping and from becoming disengaged. 



Fig. 167 





For torsoversion in upper cuspids. 
Fig. 168 





For torsoversion in bicuspids. 



208 TREATMENT OF MALPOSITION 

Fig. 167 illustrates two ways of treatment for torso version 
in upper cuspids, by means of a ligature in combination 
with the rubber wedge. The wire ligature is preferable to 
the silk ligature in the rotation of cuspids, and can be 
rendered more certain and prolonged in its action when 
combined with the rubber. 

The rotation of a bicuspid is shown in Fig. 168. In A, 
the rotation is accomplished by means of a ligature in com- 
bination with the rubber wedge; in B, a buccal movement 
is also indicated, hence the ligature only is used. The 
rubber wedge is not only inapplicable in such a case, but 
contraindicated in the first stages. 

INFRA VERSION 

As suggested by Korbitz, 1 this form of malposition may 
be either relative or absolute. A tooth is relatively too short 
when its crown is fully exposed and alveolar development 
has been arrested. A tooth is absolutely too short when 
its crown is not fully exposed and alveolar development 
apparently normal. 

Fig. 169 




For absolute infraversion in a central incisor. 



The correction of infraversion is usually accomplished 
with the alignment wire and stationary, reciprocal, or 
intermaxillary anchorage. Fig. 169 shows a case of absolute 
infraversion of an upper central which is being elongated by 



Kursus der Orthodontic 



INFRAVERSION 



209 



means of the ligature fastened to the alignment wire. The 
adjoining teeth are securely ligatured to the wire, after 
which the ligature to the malposed central is applied high 
toward the neck, and then to the wire. The silk ligature 
is preferable in such instances, and should invariably be 
passed above the cervical ridge of enamel. In lateral incisors 
and cuspids it frequently becomes necessary to adjust bands 
with spurs to prevent the ligatures from slipping. 

In cases of relative infraversion, as, for instance, in the 
so-called "open bite," the spring temper of the alignment 
wire is utilized. The wire is inserted in such a manner that 



Fig. 170 




For relative infraversion of the incisors. 



it approaches the incisal edges of the teeth to be elongated, 
and during the process of ligation is held well toward the 
gingival line, until the ligatures of all the teeth to be elon- 
gated have been attached. Upon being released, its tendency 
will be toward its original position, thus forcing the elonga- 
tion of the teeth fastened to it (Fig. 170). It must not be 
overlooked, however, that such action might also cause a 
mesial tilting of the molars; hence a more secure form of 
stationary anchorage is occasionally indicated, as shown in 
the illustration. An additional anchor band is provided for 
the second bicuspid, and the buccal tube soldered to both. 
Such precaution renders the anchorage more secure. 
14 



210 



TREATMENT OF MALPOSITION 



Intermaxillary anchorage may be used in either its 
stationary or reciprocal form, depending upon the require- 
ments of the case. If the teeth of one arch only are to be 
elongated, the alignment wire in the opposing jaw is securely 
attached to many teeth; and only to two or four in the arch 
to be treated. On the other hand, in cases where the teeth 
of both arches are to be lengthened, we can advantageously 
employ reciprocal intermaxillary anchorage (Fig. 171). 

Fig. 171 




liwiiinwiiiiwuwniiiiininiminniiiifp^ 



'innmwinwnnumwwnnw)jj^{ 




Direct intermaxillary anchorage for infraversion. 

The elongation of molars can also be effected by means of 
intermaxillary anchorage, either by direct stationary, or 
the reciprocal form. (Compare Figs. 173 and 200.) 



SUPRA VERSION 

Though supraversion is by many regarded as a common 
form of malposition, other writers maintain that it is 
extremely rare. The latter assert that supraversion is more 
apparent than real; that, in most instances, we have to deal 
with infraversion in more remote places in the arches. For 
example, the cases shown in Figs. 37 and 38 are said to 
exhibit only an apparent supraversion of the incisors; the 



SUPRAVERSION 



211 



real difficulty — so some writers believe — is an infraversion 
of the bicuspids and molars. 1 

The correction of supra version is extremely difficult, and 
can only be executed to a very limited extent. Occasionally, 
such action can be procured with the alignment wire and 
ligatures, as shown in Fig. 172. The wire is inserted into 

Fig. 172 




Ligature applied for reduction of supraversion in upper centrals. 
Fig. 173 








The reduction of supraversion in lower incisors intensified by means of inter- 
maxillary elastics. 

buccal tubes whose mesial ends point gingivally. It is thus 
brought close to the gingival line, and the ligature, being 
passed around the teeth toward their incisal edges, is tied 
while the wire is pulled incisally. Its spring causes it to 
return toward the gingival line, thus carrying the attached 
teeth with it. 
Lower incisors can be shortened in similar fashion; and 



Rogers, Items of Interest, January, 1911. 



212 TREATMENT OF MALPOSITION 

where the intermaxillary anchorage is employed simulta- 
neously (which is frequently the case in distoclusion) the 
action can be intensified (Fig. 173). 

The opposite application of the intermaxillary, e. g., in 
mesioclusion, can also be utilized, though mesioclusions 
rarely present supra version of the upper incisors. It is 
important to remember that in the application of a ligature 
for a shortening action, we must adjust it well toward the 
incisal edge, i. e., above the neck; and that such action is not 
obtainable in bicuspids. Owing to their unfavorable forms, 
being cone-like, they invariably require the use of bands 
with spurs, to prevent the slipping of ligatures. 



PERVERSION AND TRANS VERSION 

These two forms are, fortunately, extremely rare (par- 
ticularly the latter), and our means for their correction even 
more limited than in the case of supraversion. For trans- 
version there are, practically, no methods at our command; 
though theoretically, transplantation suggests itself. Per- 
version, on the other hand, is so often combined with linguo- 
or labioversion that it is frequently operable. Fig. 120 
shows the most common form met with, and one of the 
best methods yet devised for its correction. 



CHAPTER XV 

TREATMENT OF NEUTROCLUSION 

SIMPLE NEUTROCLUSION 

As intimated in Chapter XIII, the treatment of a mal- 
occlusion may embrace the correction of (a) tooth position, 
(b) arch form, (c) arch relation, and, conjointly, jaw and 
face deformity; and though each of these details is worthy 
of separate consideration, it is obvious that the goal can best 
be reached by the establishment of normal occlusion. This 
implies that each case be considered in its entirety, that all 
its various problems receive contemporaneous treatment. 
Hence we pass to a consideration of the various types. 

As elsewhere noted, most malocclusions develop slowly; 
in their early stages all are comparatively simple. We shall 
begin, therefore, with a few of the simpler forms. 

Case A. — A robust girl, aged eight years (Figs. 174 and 
175); the illustrations presenting side and occlusal views 
before and after treatment. The history of the case is 
entirely negative; the temporary teeth have never been 
affected by caries, having received regular dental attention. 
The mother of the patient believes in exercising every 
precaution, and has had the nose and throat examined by a 
rhinologist, who found them normal. Infancy was unevent- 
ful, being free from any of the serious infectious diseases 
of that period of life. The family history is also negative, 
both parents having normal dentures; hence the question 
of cause remains obscure. 



214 



TREATMENT OF NEUTROCLUSION 



Formerly it was common practice to postpone treatment 
in such cases until after the eruption of bicuspids and 
cuspids, for it was deemed impracticable, if not unwise, to 







Fig. 


174 






















-rftfi^jp^j^w ] 




■*&&fbm^ 














wWBfc^ 




mT~\ 


J^m 






'il&i 






■ 






pwVs i „^ <mm 






h^_ 








■**■ . . v .:jB 






Wj&^^W^ ^^^B 




_, 








■ JE 















Right and left views of denture before and after treatment. (Compare with 
Fig. 175.) 



move their temporary predecessors. A moment's com- 
parison of the models readily establishes the conclusion that 
it is good practice to administer treatment thus early. It 
is, of course, true that the denture of this child will require 



SIMPLE NEUTROCLUSION 



215 



further observation, and probably treatment, depending on 
the subsequent normal or abnormal eruption of the now 
unerupted teeth. But it is obvious that the enlargement 
of the dental arches has greatly increased the probability 
of their normal eruption. And further, it must be equally 
clear that the malocclusion already existing in the incisors 
will never correct itself, no matter how long the treatment 
is postponed. 





Fig. 


175 




'sijE^ 


^^;>^^Bgf|| 


K3§ 




Jmffc^* •'9 




at \\ 




^JjL • &%% 








K£^_ 




M^tr ^^^ 






/■/Vy^^^H 


W, ,\ f^ 


w 

« 




*d- A 


k'% 






HP^jbPS 


l ti 


S^^^H 




_ .^^^^fl 


^^2* 


•■^^^ 











Occlusal views before and after treatment of denture shown in Fig. 174. 

Again, the treatment of this denture did not constitute 
a hardship, and was no reason for its postponement. The 
appliances used consisted of four adjustable anchor bands 
for the first permanent molars (Fig. 113), and applied after 
the manner indicated in Fig. 112, though spurred bands 
at the mesial ends of the extension wires were considered 
unnecessary. The ends of the extension wires, after being 
cut to exact length, were bent at sharp right angles to 



216 TREATMENT OF NEUTROCLUSION 

engage silk ligatures tied to the alignment wires. The move- 
ment of the right upper central incisor was also effected with 
a silk ligature, which was renewed at weekly intervals. The 
entire treatment consumed less than four months. 

Maintenance of the corrected condition is now being 
provided by an appliance on the lower arch similar in design 
to that shown in Fig. 140, though it is anchored to the 
second temporary molars. Bands with spurs for the pre- 

Fig. 176 




Modification of appliance as advocated by Korbitz. 

vention of anterior displacement were placed upon the 
lateral incisors, instead of the canines as illustrated. In the 
upper arch maintenance is largely provided by the occlusion 
of the lower, and by a plain band with spurs upon the left 
central after the manner indicated in Fig. 135. 

An ingenious and very excellent modification of this plan 
of treatment has recently been advocated by Korbitz 1 



1 Zeitschr. f. Zahnarztl. Orthopadie, September, 1910; Deutsch. Monatssch. f. Zahn- 
heilk., November, 1910. 



SIMPLE NEUTROCLUSION 217 

(Fig. 176). He uses the hinge-joint at (a), which is procured 
by soldering an 18-gauge tube to the free end of the clamping 
bolt, which thus removes all possibility of rotation of the 
molars. He further advocates anchorage of the mesial end 

Fig. 177 




Side views of case, aged nine years, before and after treatment. (Compare 
with Fig. 178.) 

of the lingual wire to a canine band, to which he solders 
another such tube (b) at right angles. The latter is in anti- 
cipation of retention, when it will carry an 18-gauge section 
of wire extending to its fellow on the opposite side, thus 



218 



TREATMENT OF NEUTROCLUSION 



maintaining the newly established arch width. The buccal 
movement of the temporary teeth is accomplished with an 
elastic rubber band attached to a hook on the gingivolabial 
border of the canine band, then passes over a tube hook on 
the alignment wire, and on to the anchor band, all as shown 
in the illustration. The form given to the alignment wire 
controls the ultimate form of the dental arch. 



Fig. 178 





ft^SSpS 


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m 


tm • 




Bfel 


. '""' 


tv ' jH 


|^m»**MP/°' 


lUga 






•s^ft^B 


a^ 


hpf*" i i* k 'r'> * b 


^^^ ■• * f^ J| 








B|M#r ^»Ef 




*5S^%5<>^ 


2^ilBi«3 


H^^ 





Occlusal views of case shown in Fig. 177. 

Case B. — An anemic girl, aged nine years (Figs. 177 and 
178), who related a history which gave no clue as to the 
probable cause. Indeed, such local arrests of development 
as the denture of this child exhibits are difficult to account 
for. The linguoversion of the incisors could hardly be the 
result of premature loss of the temporary cuspids; the mouth 
presented an unusually healthy condition in every other 
respect, being immune to caries. Though the canines have 



SIMPLE NEUTROCLUSION 



219 



been exfoliated, it would be interesting to learn the cause 
of their early loss, which might then serve as causa prima. 

The plan of treatment was, in many respects, similar to 
that outlined for Case A, though the incisors were differently 
malposed and necessitated a slight change in the details. 
It is evident that both arches required expansion, and that 
all incisors be moved labially. The upper incisors are also 
in distoversion, with wide spaces between them. 

Fig. 179 





Maintenance appliances used for the case shown in Figs. 177 and 178. 



The appliance consisted of four molar anchor bands with 
extension wires, two 18-gauge alignment wires, and four plain 
bands with spurs for the lateral incisors. The expansion of 



220 TREATMENT OF NEUTROCLUSION 

each arch is very noticeable in the after treatment models, 

and resulted in gaining the necessary spaces for the cuspids. 

Maintenance of the corrected condition was provided by 

the appliance shown in Fig. 179. The bands upon the lateral 

Fig. 180 



Side views of case, aged eleven years, before and after treatment. 

incisors are the same as those used for movement; and the 
anchor bands upon the molars are reduced in parts by 
removal of the buccal tubes and clamping bolts, after which 



SIMPLE NEUTROCLUSION 



221 



the free lapping ends are united with solder to form a con- 
tinuous band of exact size. 

Case C. — A boy, aged eleven years (Figs. 180 and 181), 
who has suffered much from dental caries, and to whom 
mastication has for years been both difficult and painful. 
His mother related an operation for hypertrophy of the 
tonsils performed during his ninth year. Thus it is very 







Fig. 


181 




W?J+'mM 


■WK '■ fM 














m • '* 


]^H 
















^ ^_^ 





Occlusal views of case shown in Fig. 180. 

probable that the arrest of development in the upper arch 
is a result of the ailments just enumerated. 

The treatment was again similar in plan to that described 
for Cases A and B, though the lower canines were also 
involved. Hence they are included in the treatment by 
providing them with spurred bands as already described. 
Most of the temporary teeth remaining are so badly decayed 
that their immediate removal is indicated. Bv means of 



222 



TREATMENT OF NEUTROCLUSION 



the anchor bands, 16-gauge alignment wires and ligatures, 
with all of which the reader is now somewhat familiar, 
expansion of both arches was achieved as shown in the 
models. 

Fig. 182 







— " 






Facial relations before and after treatment of case shown in Figs. 180 and 181. 

Maintenance was provided for the upper arch by an 
appliance as shown in Fig. 179, and for the lower by 'one like 
Fig. 140. 



SIMPLE NEUTROCLUSION 



223 



Fig. 182 shows the facial relations before and after treat- 
ment. 

Case D. — A boy, aged nine years (Figs. 183 and 184), 
slightly below the average in height. Inquiry into his 



Fig. 183 




Side views before and after treatment of case, aged nine years. Note the 
lingual relation of the entire right upper lateral half. 



history revealed the fact that his persistent mouth breathing 
and noticeable facial deformity had led his mother to con- 
sult a rhinologist, who removed an adenoid and enlarged 



224 



TREATMENT OF NEUTROCLUSION 



tonsils about six months previously. His father, whom he 
resembles in facial expression, hair, and eye color, has a 
malocclusion of the same type, which is comparatively rare. 
The arches are in normal mesiodistal relation, though the 
entire right upper lateral half is lingual to the lower. The 
lower arch is of ideal form, and was not involved in the 





Fig. 


184 








3 








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m 




¥?' 




Hk|f ". 










■ J9H£ J * l ^^ 


m 






- ^ ^ "W 


7 : 




teta 


s 


% 1 


1 W&1j&£*^^^' "^Jfafc,, 








^ZJJ^^^Sf 


Sff 1 


Sr* b 


jp 


>- 


igj 



Front and occlusal views of case shown in Fig. 183. 



treatment. But the upper arch presents a feature that is 
interesting in its anchorage requirements. Only one lateral 
half requires a buccal movement, though the expanding 
action of the alignment wire acts with equal pressure (as 
ordinarily applied) upon both sides. Let us briefly consider 
its various methods of application, and of this controlled 
action in particular. Fig. 185 is diagrammatic of the action 



SIMPLE NEUTROCLUSION 



225 



of the alignment wire in the various ways in which it is 
ordinarily applied. In a the dotted lines indicate its expan- 
sive power toward the. buccal in each lateral half, when 
introduced with that intent. Under such circumstances it 
also tends to glide distally within the tubes, resulting in a 
lingual movement of the incisors, as shown by the arrows, 
unless such action is prevented by contact of the nuts against 

Fig. 185 




Shows the action of the alignment wire in its various applications. 



the mesial ends of the buccal tubes. If applied for con- 
traction of the arch, as in 6, its tendency in the incisal area 
will be in a labial direction, as indicated in the drawing. 
In c the distribution of the load on the molars imposed by 
the tension on the bicuspids is shown. 

The case under discussion requires that the bilateral 
buccal action of the alignment wire as shown in a, Fig. 185, 
15 



226 TREATMENT OF NEUTROCLUSION 

be rendered unilateral. This can readily be accomplished 
if the anchorage of the wire in the tube on the normal side 
is changed to complete stationary form. By soldering a 
buccal tube to the left anchor band, as shown in Fig. 186, 
and by providing it with a lingual extension wire as already 
described, the resistance was so increased as to effectually 
overcome the expanding action of the wire on the normal 
side. Its effect, therefore, was to move the right molar 
buccally, which occurred within a month's time. The 
expansion action of the wire was now slightly reduced by 
bending with the pliers, and after re-insertion the second 
temporary molar was attached. The buccal movement of 
this tooth, and of its neighbors to the mesial, was accom- 
plished by means of ligatures. 

Fig. 186 




Abell's modification of Kemple's square tube. (After Hawley.) 



Maintenance was easily provided by an appliance con- 
sisting of two molar anchor bands with lingual connecting 
wire, as shown in Fig. 179, though its anterior section was 
held in place by spurred bands upon the centrals. These 
bands were also united with solder at their mesial contact 
points, thus combining their resistance and providing 
maintenance for the corrected infraversion of the right 
central. 

COMPLEX NEUTROCLUSION 

Cases belonging to this group differ from the foregoing 
only in their minor symptoms, being identical in the funda- 



COMPLEX NEUTROCLUSION 



227 



mental characteristic, viz., the normal mesiodistal relation 
of the lower arch to the upper. They are usually older, 
however, consequently more teeth are involved, and their 



Fig. 187 




Side views before and after treatment of case, aged thirteen years. 



various features are usually emphasized in the terminology 
by the addition of qualifying phrases. The division is, 
therefore, purely arbitrary. 



228 



TREATMENT OF NEUTROCLUSION 



'■ Case E. — Neutroclusion complicated by pronounced linguo- 
version of the upper incisors and infraversion of the upper 
cuspids. A strong, healthy girl, aged thirteen years (Figs. 187 
and 188), whose non-resonant voice and marred facial 
expression before treatment (Fig. 189) were symptomatic of 
arrest of development of the intermaxillary bone and nasal 
passages, was requested to consult a rhinologist. TJie exami- 




Occlusal views of case shown in Fig. 187. 

nation revealed the presence of adenoids in the nasopharynx 
and hypertrophy of the inferior turbinates. After removal 
of this hypertrophied tissue by the rhinologist, the treatment 
of the malocclusion was begun. 

The appliances consisted of four molar anchor bands 
with buccal tubes; plain bands with spurs on the disto- 
gingival border of their lingual surfaces for the upper lateral 



COMPLEX NEUTROCLUSION 



229 



incisors and lower cuspids; and two 16-gauge alignment wires. 
The molar bands were of a design as shown in Fig. 113. 



Fig. 189 










\^,„ ^jii 









Facial relations before and after treatment of case shown in Figs. 187 and 188. 

The adjustment of the entire appliance consumed six short 
semi weekly visits, after which tension was applied. The 
alignment wires were given a slight expansive spring; the 



230 TREATMENT OF NEUTROCLUSION 

extension wires were fastened to the alignment wire after 
the manner indicated in Fig. 112, and ligatures applied to 
the lower incisors and two upper centrals. After a period 
of three weeks considerable movement had been gained, 
which in a measure liberated the interlocked upper laterals. 
Ligatures were now applied to these teeth, as well as to the 
lower cuspids. After another period of four weeks sufficient 
movement had been accomplished to permit of a more 
favorable adjustment of the upper alignment wire. By 
careful bending after the manner indicated in Fig. 130, it 
was possible to carry it sufficiently to the gingival line, so 
that it embraced the seemingly prominent canines. Its 
length was so adjusted that it rested firmly upon their labial 
eminences, thus relieving the strain upon the upper molars, 
and aiding materially in reducing the developing supra- 
version of the upper laterals, which was now asserting itself. 
It may be worthy of mention to state that the second upper 
temporary molars were extracted during the patient's 
second visit, which resulted in the immediate eruption of 
their successors. 

Maintenance has been sustained by an appliance for the 
upper arch, as shown in Fig. 179 (upper diagram), and for 
the lower as shown in Fig. 140. The improved facial lines 
resulting from the treatment are shown in Fig. 189. 

Case F. — Neutroclusion complicated by extreme labioversion 
of the upper incisors. A boy, aged nine years (Figs. 19Cf and 
191), addicted to the habit of sucking his lower lip. Several 
acute attacks of rhinitis a year previous had led the mother 
to consult a rhinologist, who failed to detect any lymphoid 
hyperplasia in the nasopharynx. And though the deformity 
is typical of an adenoid child, we are thus forced to conclude 
that the habit already alluded to is the sole cause of the 



COMPLEX NEUTROCLUSION 



231 



malocclusion. The facial deformity in this instance was 
very marked, presenting, an enlarged lower lip. 

Treatment was executed by the use of appliances identical 
with those employed for the previous cases, with addition 



Fig. 190 




Side views of Case F, before and after treatment. 



of two tube hooks on the upper alignment wire. These 
were soldered at points opposite the interproximal spaces 
between laterals and cuspids. Rubber elastics were anchored 



232 



TREATMENT OF NEUTROCLUSION 



after the manner indicated in Fig. 122, after which the 
nuts on the upper alignment wire were released. This action 
resulted in a lingual movement of the upper incisors. In 
the meantime the lower arch was liberally expanded over its 
entire length, and the upper temporary cuspids and molars 
moved buccally. 

Fig. 191 




Occlusal views of case shown in Fig. 190. 

Post-treatment maintenance is being effectually supplied 
by an appliance similar to that shown in Fig. 127, which 
provides for a continuation of the intermaxillary elastics. 
There being no permanent cuspids to anchor to in the upper 
arch, the hooks were in the nature of an extended arm from 
the two central bands (Fig. 214). 

Case G. — Neutroclusion complicated by labioversion of 
2, | 1, 2, and perversion of 1 i . A girl, aged twelve years 



COMPLEX NEUTROCLUSION 



233 



(Figs. 192 and 193), whose "prominent" upper incisors and 
consequent facial deformity led her parents to a consultation. 
They also felt certain that the delayed eruption of the right 
upper central was abnormal. A hard mass could plainly 
be felt at this point, Fig. 192, which gave assurance to 
the belief that the tooth was impacted. The father then 



Fig. 192 




Side and front views of Case G, before and after treatment. 



related the following history: He had a similar "space" 
on his left upper side, and during his seventeenth year two 
teeth erupted simultaneously, one considerably lingual to 
normal. Upon examination, his left central was found 
in labio version, and he stated that the "extra tooth" was 



234 



TREATMENT OF NEUTROCLUSION 



extracted shortly after its appearance. The mother presented 
a normal denture. Models of the father's teeth were now 
constructed, and a radiograph advised for the daughter, 
with the result shown in Fig. 12. This clearly revealed the 
presence of a supernumerary tooth, though on the opposite 
side to that of the father. After the construction of his 
models he was asked to locate, as nearly as possible, the 





• 


Fig. 


193 






Jfclf^ 


K 


j 




1 




^FF* - ' 


5-| 


t 

1 




Ik ^ 


#> 


I 




9 Hi ' 









Occlusal views of case shown in Fig. 192. 



point at which his "extra tooth" erupted. He marked same 
with a pencil at a point opposite to that shown in Fig. 
193. An anesthetic was now administered to the daughter, 
an incision made, and the supernumerary tooth removed. 
After a week's delay, during which the wound had completely 
healed, the appliances were adjusted. 

Treatment of the malocclusion was practically identical 



COMPLEX NEUTROCLUSION 



235 



with tha ( t provided for Case F, except that it included the 
extraction of all remaining temporary teeth, which the age 
of the patient justified. After several weeks of treatment 
the impacted tooth made its appearance. This was treated 
by means of a plain band and ligature as soon as it had 
erupted sufficiently, and thus brought in normal alignment. 



Fig. 194 




Retaining appliance which was modified for use in Case G. 



Maintenance was effectually provided by the appliances 
shown in Fig. 194, omitting the band upon the central 
incisor. The right central was maintained in its corrected 
position by means of a wire ligature tied around the lingual 
connecting wire. The hooks upon the upper canine and lower 
molar bands, for use with elastic rubbers, were also dis- 



236 



TREATMENT OF NEUTROCLUSION 



pensed with. The facial deformity and its correction are 
shown in Fig. 195. 



Fig. 195 







Facial relations before and after treatment of Case G. 



Case H. — Neutroclusion complicated by supra-linguowrsion 
of the incisors. An anemic boy, aged thirteen years (Figs. 
196 and 197), who has frequently been troubled with severe 
attacks of tonsilitis. Examination revealed a pronounced 






COMPLEX NEUTROCLUSION 



237 






hypertrophy of the tonsils, for which treatment by a 
rhinologist was requested. Their removal having been 
executed, the malocclusion was corrected by simultaneous 
expansion of both arches. 



Fig. 196 




Neutroclusion complicated by supra-linguoversion of the incisors, before 
and after treatment, Case H. 

The appliances for treatment consisted of four anchor 
bands and two 16-gauge alignment wires applied as in Fig. 
112 for the upper, and Fig. 167 for the lower. The right 
lower first and second bicuspids were provided with plain 
bands and spurs for their rotation, as in Fig. 168. The 
lower canines were similarly banded. The upper incisors 



238 



TREATMENT OF NEUTROCLUSION 



were carried labially by means of silk ligatures without 
banding. 

In the lower arch the four incisors were first attached. 
After considerable labial movement the cuspids were 
included, with rotary action. Subsequently the bicuspids 
were ligated to the wire. The anchor bands had been so 
adjusted that their clamping bolts embraced the second 





Fig. 


197 




W^^\ 




^r Wl 








^rt <rttex 








Hv .» "^ ?*?'^!!^ 




w 


w 




^H 




ii^^9Pr ^H 




V 


ms - - 






m* <*1 


^^mm[ 




V .' 


.*t£ * 1 






V|k 




wBtk- 


' m 


^^^1.9^"*' -«— ■- 


1 * 4» J 


■r ■ v \T ':~ 




W " ^^^^^^^ 


^^TW 


W 




F ^ v 


- ••-^ ? i^H 






k i 


/] 


^^ ' ^\«lf:. 




L 


* a 




M 




>J 




M 


J^gE? 


^B 



Occlusal views of models in Fig. 196. 



molars, thus enlisting their additional support. But it 
will be noted that the left lower lateral half has moved 
slightly distal to normal, notwithstanding the fact that 
intermaxillary anchorage was applied as soon as this ten- 
dency asserted itself. Hence its continuance was provided 
for in the retention appliance. 
Maintenance appliances consisted of an apparatus for 



COMPLEX NEUTROCLUSION 



239 



the lower as illustrated in Fig. 140, with a hook attached 
to the buccal surface of the left lower molar band for the 



Fig. 198 




Facial relations before and after treatment in Case H. 



intermaxillary elastic, and the union of the two bands on the 
right lower bicuspids. These bands were united with solder 
at their points of contact, and then reset with cement, 



240 TREATMENT OF NEUTROCLUSION 

In the upper arch an appliance like Fig. 194 (upper diagram) 
was applied, with the exception that the spur on the right 

Fig. 199 




Front views of the models of Case H, before and after treatment. 

upper cuspid band was dispensed with. Similarly, the 
incisor band shown in the drawing was prepared for the 
right central, instead of the left. 



COMPLEX NEUTROCLUSION 



241 



The vast improvement in his facial expression and general 
well-being is clearly shown in the photographs in Fig. 198. 
The correction of the occlusal plane, which had been totally 
destroyed in the anterior region of the arches by the marked 
"overbite," is shown in Fig. 199. This was only partly 
affected by the manner of application of the ligatures to the 
upper incisors (see Fig. 172); and by the action of the align- 
ment wire on the lower (see Fig. 173). The most effective 
aid for the removal of such deviations is shown in Fig. 200, 
which promotes an elongation of the posterior teeth. 

Fig. 200 








5SMSSSSSS5^^^S^g~ZIEI C ) 



Intermaxillary anchorage modified to effect elongation of the molars. 

Case I. — Neutroclusion complicated by extreme infraversion 
of the incisors, cuspids, and first bicuspids. A girl, aged 
sixteen years (Figs. 201 and 202), who was referred by a 
rhinologist after having been operated on for adenoids. 
It is extremely doubtful, however, whether they had any 
causal relation to the malocclusion. The arches are too 
symmetrical to indicate nasal involvement. Examination 
revealed an unusually large tongue, and the patient admitted 
being addicted to the habit of nursing same. 

Aside from the elongation required for all the teeth 
involved, the arches need slight alteration in form by widen- 
16 



242 TREATMENT OF NEUTROCLUSION 

ing in the region of the cuspids, and a rotation of the lower 
centrals, which are in torso version. The infraversion is, 
moreover, too extensive to warrant an attempt at correction 

Fig. 201 




Side views before and after treatment of Case I. 

by using only the spring of the alignment wire. Such an 
attempt would surely result in displacement of the molar 
teeth (see Fig. 170). Hence the use of direct intermaxillary 
anchorage (Fig. 171) was resorted to. The incisors and 



COMPLEX NEUTROCLUSION 



243 



canines were provided with bands spurred as in Fig. 203. 
These afforded secure adjustment for the alignment wires, 
and were carefully prepared and set with cement, so that 
they were all on the same plane. The intermaxillary elastics 
were worn constantly during the hours of sleep and during 
as many of the waking hours as was compatible with the 
patient's necessary comforts. 







Fig. 


202 




W& ! ' 


-^ 


%, 1 


fSff 


ttfl 


SEfcT - 
















I 1 












'vft 






i^k. ; '^ 


^T 









Occlusal views before and after treatment of case shown in Fig. 201 



During the first stages of treatment the elastic bands were 
cut from one-eighth-inch rubber tubing, and were so thin 
as to exert only gentle pressure. Gradually their thickness 
was increased, and ultimately two were applied to each side. 
These extra precautions were exercised to prevent death 
of the pulps.^ The treatment occupied a period of six months. 



244 



TREATMENT OF NEUTROCLUSION 






Maintenance has now been effectually provided by appli- 
ances of a design as shown in Fig. 140. Small hooks, con- 
structed of 20-gauge wire, were soldered to the labiogingival 
borders of the canine bands, to which light elastics were 
applied at night, and subsequently on alternate nights. In 




Shows band used for anchorage of the alignment wires in treating Case I. 

addition, the central incisors were provided with plain bands 
with spurs on their lingual surfaces, so placed as to overlap 
the lingual connecting wire. These bands were also united 
with solder before cementing into position, thus adding 
strength to the upper, and retaining the lower corrected 
torsoversions. 



CHAPTER XVI 

TREATMENT OF DISTOCLUSION 

BILATERAL DISTOCLUSION 

The distinguishing characteristic of this type of deformity 
is a bilateral distal relation of the lower arch when the teeth 
are brought into occlusion. This may be due (a) to disto- 
version of the lower teeth, (6) to arrest of development of 
the mandible, or (c) to a posterior development of the glenoid 
fossae, resulting in a posterior position of the lower jaw. 1 The 
various minor peculiarities which usually complicate cases 
belonging to this class are practically identical with those 
of complex neutroclusion. 

Bilateral Distoclusion Complicated by Extreme Labioversion of 
the Upper Incisors 

Case J. — A delicate and timid boy, aged eight years (Figs. 
204 and 205), who had adenoids removed during his fifth year 
by a rhinologist. He has, from infancy, been troubled with 
rhinitis and mouth breathing which the above-mentioned 
operation and continued nasal treatment failed to cure. He 
had recently been placed under the care of another rhinolo- 
gist, who immediately recognized the extreme dentofacial 
deformity and the utter futility of nasal treatment unassisted 
by orthodontic treatment. The facial deformity and arrest 
of development of the mandible at this time are clearly 

1 Federspiel, Proc. Amer. Soc. Orthodontists, 1911. 



246 



TREATMENT OF DISTOCLUSION 



shown in Fig. 84. The narrowing of the upper arch (which is 
symptomatic of such an abnormal nasal condition) is shown 
in the upper occlusal view of Fig. 205 (left upper corner). 



Fig. 204 




Side views before and after treatment of Case J. 



The plan of treatment adopted in this case was after the 
method suggested by Angle, for which an appliance com- 
posed of the following elements was used: Four molar 
anchor bands with buccal tubes and lingual extension wires, 
as previously described, were anchored to the first permanent 



BILATERAL DISTOCLUSION 247 

molars; two 16-gauge alignment wires with tube hooks for 
the upper; four plain bands with spurs on the distogingival 
borders of their lingual surfaces for the upper incisors. The 
lower incisors were tied to the alignment wire with silk 
ligatures. The lingual extension wires were similarly fastened 
to the alignment wire for the expansion of the lower arch. 

Fig. 205 




Occlusal views of Case J. 

This apparatus furnished the source of anchorage for inter- 
maxillary elastics attached to the tube hooks on the upper 
wire (see Fig. 122). 

In the early stages of treatment only the lingual wires 
were tied to the upper alignment wire, to promote buccal 
movement of the upper temporary teeth. The nuts mesial 
to the buccal tubes were so adjusted that the alignment wire 



248 TREATMENT OF DISTOCLUSION 

on the upper arch failed in contact with the labial surfaces 
of the incisors. Hence the pressure of the intermaxillary 
elastics was entirely exerted upon the upper first permanent 
molars, resulting in their full distal movement. This being 
accomplished, the nuts were released and the alignment 
wire allowed to rest upon the incisors, which resulted in a 
reduction of their labio version. Finally, ligatures were 

Fig. 206 





Facial relations of Case J after four months of treatment. (Compare with Fig. 84.) 

passed from the lingual spurs on their bands to the align- 
ment wire to effect their rotation. Such ligation in the 
earlier stages must always be dispensed with, to avoid 
undue elongation. 

The treatment up to the time of maintenance occupied 
a period of four months. The occlusion of the teeth at this 
time is shown in the illustrations already referred to, and the 
vast improvement in facial balance is set forth in Fig. 206. 



BILATERAL DISTOCLUSION 249 

It may be of interest to note that mouth breathing ceased 
entirely during the second month of orthodontic treatment. 

Maintenance is being successfully accomplished by an 
appliance similar to that shown in Fig. 179, though the 
following minor alterations were necessitated by the disto- 
clusion. The lower molar bands were provided with small 
hooks constructed of 20-gauge iridioplatinum wire attached 
to their mesiobuccal angles, close to the gingival margin. 
The two bands upon the upper lateral incisors were connected 
with a labial wire of the same gauge, which was bent into 
hook form at each end, immediately distal to the canine 
embrasure. During the first month of retention, delicate 
elastics were worn continuously. Subsequently their use 
was limited to the hours of sleep, and in the last half of 
the first year to the sleeping hours on alternate nights 
only. 

The entire appliance was now removed and the teeth 
thoroughly cleansed, after which it was reset. The latter 
precaution was for a twofold purpose; partly to maintain 
the form of the arches, but more especially to exert a con- 
trolling influence on the erupting bicuspids. In this stage 
of retention the lingual wire is of inestimable value. The 
growth in the mandible during the last year has been very 
marked. 

Case K. — A strong boy, aged twelve years (Figs. 207 and 
208), whose history does not relate nasal treatment. Nor 
did an examination by a rhinologist reveal any pathological 
nasal condition, though he is a confirmed mouth breather. 
It will be noted, too, that the occlusal views of the pre- 
treatment models (Fig. 208) exhibit rather symmetrical 
arches with very little arrest of development. The facial 
deformity is not nearly as severe as in Case J. There can be 



250 



TREATMENT OF D1STOCLUS10N 



no doubt that this deformity was easily recognizable during 
his sixth year, possibly earlier, though on this point his 
parents are not certain. Such malocclusions are frequently 



Fig. 207 




Side views before and after treatment of Case K. 



attributed to nasal obstruction, and explained on the 
hypothesis that adenoid vegetations were undoubtedly a 
contributing cause during childhood, and that their resorp- 
tion (which is known to occasionally take place) has removed 



BILATERAL D1ST0CLVSI0N 



251 



every trace of them. But that is purely an hypothesis and 
difficult of conclusive demonstration. 

Furthermore, this boy provides the following interesting 
family history : His father is dark haired, of English descent, 
presents an extreme bilateral distoclusion of a type under 
consideration, and a very decided dolichocephalic head 
form. In short, his is a typical adenoid face. His mother, 

Fig. 208 




Occlusal views of Case K. 



on the other hand (whom he strongly resembles in com- 
plexion, hair and eye color, as well as in tooth form), is of 
Celtic extraction, of the reddish blonde type, with freckled 
skin, with prominent malar bones, brachycephalic head form, 
and prognathous denture (though normal in occlusion). 
Hence the temptation to blame heredity for the deformity, 
to speak of it as an inherited disharmonism. But this would 



252 TREATMENT OF DISTOCLUSION 

again be purely an hypothesis and equally difficult of veri- 
fication. 

Treatment was similar to that described for Case J, 
though the lingual extension wires were dispensed with in 
the upper arch. The molar anchor bands were adjusted 
with their clamping bolts pointing distally. After the 
normal mesiodistal relations between the molars had been 
established by means of the intermaxillary elastics, the 
upper molar bands were removed and bands placed upon 
the second bicuspids. The first bicuspids were attached 
to these with wire ligatures. After their distal movement, 
the nuts were released and pressure brought to bear upon 
the upper incisors. In the meantime the lower arch was 
gradually enlarged for the accommodation of the left 
canine. 

An interesting feature of the case was a porcelain crown 
upon the left upper central incisor, but which did not become 
the seat of any discomfort. There being no torsoversion 
present in any of the upper incisors, plain bands were 
contraindicated. 

The retention appliance was identical in design to that 
described for Case J. The bands shown in the after treat- 
ment models of the illustrations were substituted for same 
at the close of the period of retention. 

Case L. — A youth aged nineteen years (Figs. 209 and 210), 
showing complete distoclusion as a result of postponement of 
treatment. Note the extreme narrow upper arch, and the 
pronounced labioversion of the upper incisors. This case 
is a fine exhibition of the axiom set forth in the chapter on 
Prognosis, that nature and time rarely exert a corrective 
influence on a malocclusion. 

The improvements in the occlusion of the teeth shown in 



BILATERAL DISTOCLUSION 



253 



the illustrations were accomplished in the short period of 
four months. The case is one of the first the author ever 
attempted to treat, and as he now reflects over his seeming 
achievement, he is quite convinced that a radical change 
in the temporomandibular articulation, viz., the mounting 

Fig. 209 




Side views before and after treatment of Case L. 



of the condyles on the eminentia articularis, was largely 
responsible for the results. 

The treatment was identical to the plan already described, 
though retention was provided with vulcanite plates with 
labial wires. The effect upon the facial lines is shown in 



254 TREATMENT OF DISTOCLUSION 

Fro. 210 









i 






'^r- ^ 


'r" 


i ^F^ 


• 


( Hf' 


1 


n 


^^ 




- 


1 


2^ 



Occlusal views of Case L. 



\ 



Fig. 211 






Profile of Case L, before and after treatment. 



BILATERAL DISTOCLUSION 



255 



Fig. 211. The corrected condition was readily maintained 
for two years, during which time the patient was under the 
author's care. Since then he has lost all trace of him, and 
he regrets that the ultimate results are not now available. 



Fig. 212 




Side views of Case M. 



Such extreme deformities form interesting studies from 
various points of view. First, they recall the inclined plane 
of Catalan and Kingsley for "jumping the bite;" second, 
they emphasize the many recent criticisms directed against 



256 TREATMENT OF DISTOCLUSION 

that plan of treatment; third, they forcibly impress one with 
the necessity for early treatment, since they offer convincing 
proof that neglect frequently results in jaw deformity, after 
which the accompanying malocclusions are but symptoms. 
(See Chapter XVIII.) 

Bilateral Distoclusion Complicated by Linguoversion of the 
Upper Incisors 

Case M. — A girl, aged ten years (Figs. 212 and 213), with 
negative history. The facial deformity was marked, and 
of a type as illustrated in Fig. 83. The prognosis of cases 







Fig. 


213 








O-SP.^^ 


W& 


WSea 


we r ' ' 


fi&^w^ 










\ - 
















[ V* 


mmmmm 








Y,-lfijj^-' J 



Occlusal views of Case M. (The lower models should be transposed.) 

belonging to this group has previously been emphasized, 
the tendency being toward an arrest of development in the 
mandible (see Fig. 89). Postponement of treatment would 
unquestionably result in an aggravation of the deformity. 



BILATERAL DISTOCLUSION 



257 



Treatment was instituted by means of anchor bands, 
alignment wires, plain bands for the upper incisors, and 
intermaxillary elastics. The details of application are in 
many respects similar to those described for the former 
group, though there is need for less widening of the arches. 
Furthermore, the upper centrals require a labial movement, 
which can easily be accomplished by reciprocal anchorage 
in combination with the lingual movement of the adjoining 
laterals (see Fig. 147). 

Fig. 214 





Retaining device for the upper arch of Case M, providing for a continuance 
of the intermaxillary elastics. (After Rogers.) 

As pointed out by Angle, the loss of occlusion of the 
anterior teeth permits their elevation, so that the treatment 
should aim at a reduction of their supr aversion. But in 
view of the fact that such action is extremely difficult to 
obtain, and a growth of the mandible especially desirable, 
the plan illustrated in Fig. 200 (resulting in an elongation 
of the molars) has been widely accepted. 

Such continued action of the intermaxillary elastics is 
now provided for in the retaining appliance (Fig. 214). The 
17 



258 



TREATMENT OF DISTOCLUSION 



bands upon the centrals are united and attached to the 
lingual wire, which extends to the molar bands, thus pro- 
viding for maintenance of arch form. In addition, an 
inclined plane of metal is provided, and so adjusted that the 



Fig. 215 




Side views, before and after treatment, of Case N. 



"bite" will remain open to the desired height (section a-a). 
On the labial surfaces of the incisor bands extended hooks 
are provided for the fastening of the elastics, which are also 
attached to hooks on the upper and lower molar bands. In 



BILATERAL DISTOCLUSION 



259 



the lower arch the appliance usually follows the design 
illustrated in Figs. 140 and 179, depending on whether the 
canines have, or have not, erupted. 

Case N. — A girl, aged thirteen years, the daughter of a 
physician, with negative history (Figs. 215 and 216). The 
etiology in such cases is still obscure ; they are in all probabil- 
ity due to intrinsic factors which we have failed to recog- 









Fig. 


216 




















V^^^H 


'*.%*> 


WB 1 




r v 




1 

i a 






Wyl 






wzi 


XilW 



Occlusal views, before and after treatment, of Case N. 



nize. The normal nasal and lip function . accompanying 
this type naturally implies facial deformities less severe 
than in the group complicated by labioversion of the upper 
incisors and nasal obstruction. A well-developed mental 
eminence in this case especially precluded the possibility 
of severe facial deformity (Fig. 217). 

The details of treatment were practically the same as 



260 



TREATMENT OF DISTOCLUSION 



for the former case, except that the laterals were carried 
labially with the centrals, and the rubber wedge for reciprocal 
action applied to the canines. The bicuspids were carried 



Fig. 217 







Facial relations, before and after treatment, of Case N. 



slightly buccally, and distal movement of the upper and 
mesial movement of the lower molars affected by inter- 
maxillary^ elastics . 



BILATERAL DISTOCLUSION 



261 



For maintenance after tooth movement, an appliance as 
shown in Fig. 140 was applied to the lower arch, with the 
addition of hooks to the buccal surfaces of the molar bands. 
In the upper arch a plain band upon each lateral was con- 
nected with a wire- on the labial extending distally beyond 



Fig. 218 




Side views, before and after treatment, of Case O. 



the labial eminences of the canines and ending in a hook, 
for the reception of intermaxillary elastics anchored to the 
lower molars. These were worn during the sleeping hours for 
a period of six months, then on alternate nights only for the 
remainder of a year, after which all appliances were removed. 



262 



TREATMENT OF DISTOCLUSION 



Case O. — A boy, aged fourteen years (Figs. 218 and 219), 
who presents an extreme deformity. An unusual feature of 
the case is the arrest of development of the arches, with 
linguoversion of the upper molars and bicuspids. This 
rarely is so severe in cases with linguoversion of the incisors. 







Fig. 


219 










£)w • 




#S 


^ 


«&r .. 


' ', \. *' x" 5 


fe) 1 


/ 


**■>. 


\ 


*J 


%■ 


' il 


• .* 


4„; 


A 


*m 


Bi^^^BWiil^SPP\ 


> ■ 






m f. 


^^^F 


sammm 


mm^ 


^' 




i M ,| ri --m 


^m - % i mm. 






I 






K f » 


$,."■ 


; •». 


k 




y-i:/ 


■ 


„ ■ ' 


1 


1* 






SftiB^ 


y 


' 


%^1 


1 



Occlusal views, before and after treatment, of Case O. 



A study of the case readily reveals the requirements of 
treatment; both arches require considerable expansion; the 
lower arch a mesial movement; the upper a distal move- 
ment for molars, bicuspids, and canines, and labial move- 
ment for the lateral incisors. The upper central incisors 
occupy an approximately normal position, labiolingually, 
though all four incisors demand a correction of their torso- 



BILATERAL D1ST0CLUS10N 263 

version. The various details were carried out as follows: 
Molar anchor bands were fitted to the lower first molars 
and bands adapted to the lower canines, with spurs on the 
distogingival borders of their lingual surfaces. The clamp- 
ing bolts on the anchor bands were allowed to point distally, 
thus embracing the second molars (Fig. 167). After all the 
lower teeth were tied to the lower alignment wire, and 
expansion of the lower arch thus prepared for, the upper 
molar anchor bands with buccal tubes were similarly placed. 
An alignment wire with tube hooks opposite the upper 
canines was now inserted as high, gingivally, as the canines 
would permit, though not encircling them, and the nuts 
so adjusted that it failed to rest upon the incisors. The 
application of intermaxillary elastics from lower molar 
tubes to upper hooks (first one for each side, then two), 
caused a distal movement of the upper molars. The expand- 
ing action of the alignment wire produced their buccal 
movement, the clamping bolts carrying the second molars. 
This occupied a period of two months. The upper molar 
bands were now removed, and similar bands placed upon 
the upper second bicuspids, with their clamping bolts 
pointing mesially to embrace the first bicuspids. The latter 
were tied to the anchor bands by means of wire ligatures, 
gauge 26. The upper alignment wire was reinserted and its 
adjustment so controlled that it encircled the canines and 
rested firmly on their labial eminences. The incisors were 
now attached with silk ligatures as in Fig. 165, and the 
action of the intermaxillary elastics resumed until the rela- 
tions shown in the after-treatment models were established. 
The lower arch was provided with an appliance as in 
Fig. 140, though the clamping bolts on the molar bands were 
retained. Hooks were also soldered to the buccal surfaces 



264 



TREATMENT OF DISTOCLUSION 



after the buccal tubes were detached, as previously described. 
In the upper arch an appliance similar to that in Fig. 179 
(upper diagram) was adjusted. The anchor bands origin- 
ally used on the upper first molars were employed, and their 
clamping bolts pointing in a distal direction allowed to 
remain. The two plain bands upon the laterals were con- 
nected with a labial wire bent into hook form at each end, 
and of sufficient length to embrace the canines. The main- 
tenance of the corrected arch form was thus provided for, 
as well as the arch relation by continued use of the inter- 
maxillary elastics. 

Fig. 220 




Modification of intermaxillary force for correction of labio-infraversion compli 
eating distoclusion. 



Bilateral Distoclusion, Complicated by Labio-infraversion of 
the Upper Incisors 

This type of malocclusion is exceedingly rare. Fig. 41, B, 
shows the right view of a case from the author's practice, 
being a girl, aged nine years. The central incisors began 
erupting during the seventh year, but the pernicious habit 
of tongue-sucking prevented them from assuming a normal 
length. The patient was also afflicted with hypertrophy 
of the tonsils and inferior turbinates. In the treatment, 



UNILATERAL DISTOCLUSION 265 

the ligation of the incisors is not only immediately desir- 
able (which was contraindicated in the cases previously 
described), but should even be intensified by the appli- 
cation of the elastics as in Fig. 220. 

Fig. 221 




Side views, before and after treatment, of Case P. 

UNILATERAL DISTOCLUSION 

As its name implies, cases belonging to this group 
present a distal relation of the lower on one side only, 



266 TREATMENT OF DISTOCLUSION 

the other side being as in neutroclusion. The compli- 
cations are similar to those affecting the bilateral types. 

Unilateral Distoclusion, Complicated by Labioversion of the 
Upper Incisors 

Case P. — A boy, aged twelve years (Figs. 221 and 222), 
who had an operation for adenoids performed during his 
tenth year, and who is still under treatment for chronic 
rhinitis. The distal closure of the lower is readily seen in 





Fig. 


222 






j^jgftaBySBp^^ 


i^^B 




bi^^t 


iJ5^ 


w&HbjKt "'- Z&\ 










«3^i§F 


m 








■i^^^H 






; ' .1 .... 


' im 




^^m 




^^ 


■A 



Occlusal views, before and after treatment, of Case P. 

the right view of the pre-treatment models, as are also 
the other minor complications with which the reader has 
become familiar through a consideration of the bilateral 
type. These are briefly enumerated by Angle as follows: 
Narrowing of the upper arch, elongation of the upper 



UNILATERAL DISTOCLUSION 



267 



incisors, abnormal nasal and lip function, and distortion 
of the facial lines. (Compare with Figs. 204 and 205). 



Fig. 223 




Facial relations, before and after treatment, of Case P. 



The first requirement of the treatment which naturally 
suggests itself is the mesiodistal shifting of the right lower 
and upper first molars, by means of reciprocal intermaxillary 



268 



TREATMENT OF DISTOCLUSION 



anchorage. Following this should come the widening of 
the arches, especially in the bicuspid region, as well as 
a correction of their mesiodistal relation on the affected 



Fig. 224 




Side views, before and after treatment, of Case Q. 



side. The nuts on the upper arch are now released and 
pressure allowed to fall upon the protruding incisors, for 
the reduction of their labio version. 

Maintenance was in every respect similar to that described 
for Case J, with the exception that the continuance of 



UNILATERAL DISTOCLUSION 269 

intermaxillary force during the sleeping hours was provided 
only for the right, or previously abnormal side. Fig. 223 
shows the marked improvement in the facial relation. 

Unilateral Distoclusion, Complicated by Linguo-supraversion of 
the Upper Incisors 

Case Q. — A young miss, aged sixteen years (Figs. 224 and 
225), with negative history, presenting normal nasal and 
lip function, and but slight distortion of the facial lines. 









Fig. 


225 






r^ kJ gtf^ 


P* \^1 




HP 












^.-^ 








^^ m 








r i 


^gg 


H»]Q| 






F* x ^ 



Occlusal views, before and after treatment, of Case Q. 

Treatment consisted in first moving the left upper molars 
and bicuspids distally (as previously described), after which 
the upper incisors were moved labially, and by a continuation 
of the intermaxillary elastics a mesial tipping of the lower 



270 



TREATMENT OF DISTOCLUSION 



Fig. 226 




Modified application of intermaxillary anchorage for median line deviations. 
(After Reoch.) 



Fig. 227 




Modification for simpler deviations, (After Angle.) 



UNILATERAL DISTOCLUSION 271 

left side was effected. The left upper canine, having pre- 
viously been provided with a plain band with a spur upon 
its lingual surface, at its mesiogingival angle, was likewise 
moved into normal position in the arch. 

The corrected torsoversion in the upper central incisors 
was maintained with two plain bands united by solder at 
their mesial contact points. The band upon the left upper 
canine was replaced after a hook had been attached to the 
distogingival angle of its labial surface. The left lower 
molar band was provided with a similar hook on its buccal 
surface after the buccal tube was detached, and an elastic 
was then applied to them nightly. This was continued for 
some eight months, after which they were removed, with 
the occlusion improved to a normal relation. 

In extreme cases of unilateral distoclusion pronounced 
deviations of the median line frequently exist. To over- 
come such marked deviations, particularly in older patients, 
the application of an elastic on the normal side, as in Fig. 
226, may at times be indicated. In less severe cases, but 
which do not yield after continued application of the elastic 
on the normal side, and in cases of neutroclusion and 
unilateral mesioclusion which may present such deviations, 
the application of an elastic as in Fig. 227 is indicated. 



CHAPTER XVII 

TREATMENT OF MESIOCLUSION 

BILATERAL MESIOCLUSION 

It will be recalled that the cases comprising this group 
are characterized by a bilateral mesial relation of the lower 
arch. This may be due to (a) mesio version of the lower 
teeth, (6) to a forward position of the mandible and its 
articular fossa?, or (c) to an overdevelopment of the bone, 
either in its body or ascending rami, or both. And though 
very little is definitely known regarding their etiology beyond 
the factor proposed by Case (see page 71), all observers 
agree that deformities of this type begin at an early age. 
Not infrequently arrest of development of the maxilla, as 
well as various versions of a number of the teeth, are found 
as complications. Extreme conditions in patients of ad- 
vanced years are more properly classified as presenting 
mandibular deformities, the alleviation of which lies beyond 
the scope of orthodontics (see Chapter XVIII). 

The accompanying facial deformities are often pro- 
nounced, and naturally the reverse of those aggravating 
distoclusions. Some of the milder forms resemble those of 
neutroclusions complicated by linguoversion of the upper 
incisors (compare Figs. 182 and 236). 

Case R. — A girl, aged ten years (Figs. 228 and 229), 
afflicted with hypertrophy of the tonsils, gave a history of 



BILATERAL MESIOCLUSION 



273 



chronic "sore throat." She was referred to a rhinologist 
for removal of the enlarged tonsils and such treatment of 
the nose and throat as to him seemed necessary. The 
improvement of the voice and breathing which followed 



Fig. 228 




Side views of Case R. 



was marked. Attention is also directed to the premature 
loss of the lower first permanent molars, which occurred 
during her sixth year. These were affected by extensive 
caries and consequent pulp exposure, but their extraction 
was a serious blunder, and not only failed to correct the 
18 



274 



TREATMENT OF MESIOCLUSION 



deformity, but undoubtedly aggravated it by compelling 
mastication with the anterior teeth. 



Fig. 229 




Occlusal views of Case R. 



Fig. 230 



V 



^nw^^^^rj- 'Z~ L - 




Manner of applying intermaxillary anchorage for mesioclusions. 



The best plan for the treatment of these cases is illus- 
trated in Fig. 230, being a reversal of the intermaxillary 
anchorage employed in distoclusions. In the case under 
discussion the upper arch was provided with molar anchor 



BILATERAL MESIOCLUSION 



275 



bands and alignment wire after the manner already described. 
In the lower a decided modification was necessitated by the 
absence of the permanent first molars. Hence the canines 
were provided with plain bands with lingual seam, which 
were then united by a labial wire soldered to their gingival 
margins and terminating in a well-formed hook at each end. 
The latter offered anchorage for the intermaxillary elastics 

Fig. 231 




' 




Facial relations of Case R, before and after treatment. 



stretched from the buccal tubes of the upper molar bands. 
The author's first aim was to induce development of the 
upper arch and to restore occlusion of the anterior teeth — 
to bring them under the control of normal influences. Semi- 
weekly visits extending over a month's time readily accom- 
plished this, with a change in the profile as shown in Fig. 231. 
This result was so gratifying that the author felt confident 
the complete control of the deformity was now assured. 



276 



TREATMENT OF MESIOCLUSION 



Hence the upper appliance was removed and a retainer 
after the design shown in Fig. 179 (upper diagram) sub- 
stituted. The molar bands were provided with buccal hooks 
pointing in a distal direction, thus offering attachment for 
continued use of the elastics. 

Fig. 232 




Side views of Case S, showing the progress attained during three and one-half 

months. 



The case was now dismissed, with the request for monthly 
visits. At the close of the first year the post-treatment 



BILATERAL MESIOCLUSION 277 

models shown in the half-tones were constructed, and further 
treatment is now in progress. The eruption of the second 
molars has taken place, as will be noted, and treatment 
of the remaining versions rendered less difficult. 

Fig. 233 




Occlusal views of Case S. 

Case S. — A girl, aged ten years (Figs. 232 and 233), who 
had hypertrophied tonsils removed during her sixth year. 
Orthodontic treatment was postponed for one year with the 
hope that the left upper first permanent molar would make 
its appearance. But not until the tenth year did this 
occur (see left view in right upper corner of Fig. 232). 
Treatment was begun February, 1911, and the left upper 
temporary molar used for anchorage, this tooth being still 
very firm. The second models shown in the illustrations 
were made in May (current year) just prior to the patient's 
departure for an extended trip. 



278 TREATMENT OF MESIOCLUSION 

A gratifying change in the progress of the first molar is 
noticeable; in fact, the eruption has so far progressed that 
the temporary retaining device was anchored to it. The 
eruption of the upper canines and first premolars was pro- 





Fig. 


234 








^f^^^ 


- V 




i?8l 










■rata 


t- ^ 








JEa 


fc* 






r'l 








: '•- -■-■£ 












^T 


, 


T"' ^^B 


if* 


fl 


C^ 


r " T 






^^^^^_ 













Side views, before and after treatment, of Case T. 

moted by the extraction of their temporary predecessors 
immediately after the first models were made. 

The maintenance provided is similar to that for Case R, 
though the upper left lateral band has a spur of 20-gauge 



BILATERAL MESIOCLUSION 



279 



wire attached to its labial surface which extends over the 
erupting canine. The labial wire on the lower arch is 
attached to bands upon the lateral incisors, and extends 
distally to embrace the erupting canines. The use of inter- 
maxillary elastics has been advised during the entire vaca- 
tion period to promote growth, as well as maintenance, of the 
established relations. A resumption of treatment for a short 







Fig. 


235 






i 


iS^ 




A 


^p{53 


jg» 


h 


*? 


,w 


J 


e^Bb 


V© 




V 


tk\tr 


V 


sip* - 


„, ■? 


f 


jH^k 




4 




>~'J?^?I 


x\ 




}T \ - M 


1 


*y^mk 


r WMm 


\ 


■^ 


rDkWL^Mm 




K»5f. HB 


Bar 


'jiff \ 


3§^ 













^*« 


pr 



Occlusal views, before and after treatment, of Case T. 



period during the coming autumn will effect a complete cure. 
The change in the facial relations were equally as gratifying 
as in Case R. 

Case T. — A boy, aged eleven years (Figs. 234 and 235), 
who was referred by a rhinologist after being treated for 
hypertrophy of the tonsils. Treatment after the manner 
outlined for Cases R and S not only improved the facial 
expression (Fig. 236), but his general health as well. 



280 



TREATMENT OF MES10CLUSION 



Maintenance was provided by an appliance as shown 
in Fig. 194, omitting the band upon the upper central 
incisor and reversing the attachment of the hooks for 



Fig. 236 




Facial relations, before and after treatment, of Case T. 



reversal of the intermaxillary elastics. In other words, 
the lower canines and upper molar bands were utilized 
for anchorage of the rubbers. 



UNILATERAL MBSIOCLUSION 



281 



UNILATERAL MESIOCLUSION 

As its name implies, this type of malocclusion presents 
mesial closure of the lower arch on one side only, the relation 

Fig. 237 




Side views, before and after treatment, of Case U. 



being neutral upon the other. Its possible combination 
with a unilateral distoclusion — mesiodistoclusion — consti- 
tutes what Angle has designated as Class IV. 



282 TREATMENT OF MESIOCLUSION 

Unilateral mesioclusions are extremely rare, and their 
accompanying complications are usually less pronounced 
than in the bilateral types. The etiology is even more 
obscure, though the treatment is decidedly easier, and 
rarely, if ever, beyond orthodontic technique. 

Fig. 238 




Occlusal views, before and after treatment, of Case U. 

Case U. — A boy, aged thirteen years (Figs. 237 and 238), 
with negative history so far as his childhood and infancy are 
concerned, but whose father has a malocclusion of identical 
form. There was a time when heredity would have explained 
this otherwise unexplainable phenomenon, but we have 
learned "not to spell heredity with a capital 'h.' We no 
longer think of it as a power or as a principle, as a fate or 
as one of the forces of nature." Heredity is now merely 
regarded as a "convenient term to express the genetic rela- 



UNILATERAL MESIOCLUSION 283 

tion between successive generations," and though we know 
infinitely more about it than formerly, we have not yet 
succeeded in "measuring and weighing" such resemblances. 
Treatment consisted in the application of molar anchor 
bands and alignment wires for the development of each 
arch and for the application of an elastic on the left side 
as in Fig. 230. The upper incisors and lower canines were 

Tig. 239 



m 




Profile of Case U after treatment. (Compare with Fig. 67.) 

provided with plane spurred bands for the more secure 
attachment of their ligatures and to effect rotation, as well 
as labial movement, of the incisors. 

Maintenance was procured by an appliance like that 
shown in Fig. 140 for the lower, and Fig. 179 (upper diagram) 
for the upper. The improvement in the facial balance can 
readily be noted by comparing Fig. 239 with Fig. 67. 



CHAPTER XVIII 
TREATMENT OF MALFORMATIONS OF THE JAWS 

Though the achievements of orthodontics are truly 
wonderful, it is well that we recognize its limitations. 
Indeed, its methods are now conceded to be inadequate for 
the treatment of those extreme deformities which involve 
the jaws, and to which the reader's attention has already 
been called. Fortunately, the skill of the oral surgeon 
frequently offers much hope to those afflicted with these 
very distressing disfigurements. 

In view of the fact that malocclusion of the teeth invari- 
ably accompanies such deformities and frequently stands in 
causal relation to them (thus demanding the cooperation 
of the orthodontist), it seems eminently appropriate to 
close the volume with a brief review of recent advances in 
this field. But the remedial measures about to be described 
are entirely of a surgical nature, which precludes a detailed 
discussion of their technique. Moreover, the author con- 
fidently believes that no definite set of rules can be laid 
down for guidance; such decision must rest entirely with the 
surgeon. However, it is of the utmost importance that 
the operator carefully consider the degree of deformity, the 
anesthetic, the most suitable operation for a given case, 
the best method for postoperative immobilization of the 
parts, etc. In the latter phase, the orthodontist can 
frequently render invaluable service. 



TREATMENT OF MALFORMATIONS OF THE JAWS 285 

Oral deformities requiring surgical interference were 
partly enumerated in Chapter V as follows: 

1. Macrognathism, overdevelopment of a jaw. 

2. Micrognathism, arrested development of a jaw. 
These may be more specifically designated according to 

their location by the addition of such prefixes as man- 
dibular, maxillary, and bimaxillary, and by combinations 
of them. To this list (as was then intimated) must be 
added all those deformities with which the oral surgeon 
has to deal. The latter include: 

3. Malposition of the mandible. 

4. Curvature of the mandible. 

5. Congenital deformities, such as clefts of the palate, 
agnathism, polygnathism, etc. 

6. Deformities due to abnormal extraneous influences, 
such as blows, burns, fractures, etc. 

7. Deformities resulting from disease — fibroma, ankylosis, 
etc. 

The most pertinent of these are mandibular macrogna- 
thism, micrognathism, curvature, and malposition. 

The historical development of the surgical measures 
proposed for the alleviation of these deformities was briefly 
set forth by Babcock 1 in a paper read before the ninth 
annual meeting of the American Society of Orthodontists 
held in Cleveland, October, 1909, from which the following 
is a quotation: 

"As to the history of what has been done in these opera- 
tions on the jaw, a brief summary may be permitted. It 
is, indeed, surprising how few operations have been done. 
Starting in 1848, Dr. S. P. Hullihen, 2 of Wheeling, W. Va., 

1 Items of Interest, June, 1910. 

2 Amer. Jour. Dental Science, 1849, p. 157. 



286 TREATMENT OF MALFORMATIONS OF THE JAWS 

did the pioneer operation for an elongated jaw, with prog- 
nathism. We should name him with a great deal of pride. 
He had to do with a patient who had been under the care 
of some of the best surgeons in New York, only to meet with 
failure and rather an increase of the deformity. Anesthesia 
was not generally available, the germ theory and antiseptics 
were not understood, hemostatic forceps had not been 
invented, and much in the way of surgical technique was 
yet to be evolved, but this man had the hardihood to go 
ahead and do a series of very extensive operations upon 
this girl's jaw and neck, which resulted in a remarkable 
improvement, if not a complete restoration. The case was 
that of a girl, aged twenty years, who fifteen years before 
had been so badly burned over the neck that the jaw was 
pulled down upon the chest, and there had been produced 
an elongation of the mandible, a protrusion of the lower 
incisors, and marked e version of the lower lip. 

"With a small saw V-shaped sections were resected from 
each side of the jaw, the section upon the left side including 
the bicuspids. The V-shaped sections extended two-thirds 
of the way through the bone, the apices being below (Fig. 
240). From the apices the saw was turned horizontally 
forward, completing the section, and leaving the upper 
two-thirds of the anterior portion of the mandible attached 
to the soft tissues of the lip only. With the removal of the 
two V-shaped sections of bone the mobilized portion of the 
jaw could be pushed back into place, securing an occlusion 
of the incisors (Fig. 241). From an impression taken in soft 
wax a silver plate was then struck up, which, when applied, 
held the section of the jaw in proper position. Union rapidly 
occurred, and Dr. Hullihen then boldly proceeded to correct 
the defect in the neck. A large flap of skin from the shoulder 



TREATMENT OF MALFORMATIONS OF THE JAWS 287 

and arm was transplanted to the neck, enabling the head to 
be raised, and finally by two further operations the everted 
and deformed lower lip was made sightly and useful. All 
of these operations are said to have been successful. 

Fig. 210 




Diagram showing type of deformity in Hullihen's case, the dotted lines indicating 
the lines of bone section and the triangular segments of bone to be removed. (After 
Babcock.) 

Fig. 241 




Diagram of Hullihen's case, showing his method of correction. (After Babcock.) 

"Nearly fifty years elapsed before bilateral resection of 
the mandible was again suggested. In 1896 Dr. R. Otto- 
lengui, 1 in discussing the subject, suggested the feasibility 
of such a procedure, and the following year Dr. Tames W. 



Dental Cosmos, 1897, p. 143. 



288 TREATMENT OF MALFORMATIONS OF THE JAWS 

Whipple, 1 of St. Louis, referred to Dr. Edward H. Angle 
a patient, a young man, with a progressive type of prog- 
nathism. After studying this patient, Dr. Angle advised 
a bilateral resection of the elongated portions of the jaw, 
between the first molar and second bicuspid on the right side, 
and the first and second bicuspid on the left side, the sections 

Fig. 242 




Profiles of patient before and after double resection of the mandible. (After Ballin.) 



removed differing from those removed by Hullihen, inas- 
much as the removed segments passed through the entire 
depth of the body of the jaw. This operation was not 
performed by Dr. Angle, and the patient finally came under 
the care of a surgeon, Dr. V. P. Blair, who resected a quadri- 

» Dental Cosmos, 1898, p. 552. 



TREATMENT OF MALFORMATIONS OF THE JAWS 2S9 

lateral section from each side of the jaw, brought the teeth 
into occlusion, wired them in place, and then found great 

Fig. 243 




Dental models before and after operation; the lines a and b indicate section 
removed. (After Ballin.) 
19 



290 TREATMENT OF MALFORMATIONS OF THE JAWS 

difficulty in holding all the fragments of the jaw in occlusion. 
However, after nine quite troublesome weeks from suppura- 
tion and some necrosis, bony union and a very creditable 

Fig. 244 




Typical deformity, with dotted lines indicating the various possible sections. 
Section made from b to d. (After Babcock.) 



result were obtained. 1 The publication of this operation 
led to a few similar operations, which in some cases were 



1 Dental Cosmos, August, 1906, 



TREATMENT OF MALFORMATIONS OF THE JAWS 291 

followed by necrosis, one patient in New Orleans losing 
the mandible from this cause. Although this operation is 

Fig. 245 





Shows possible correction after sections a-b or a-e. (After Babcock.) 



performed through incisions from below the jaw, the two 
compound fractures into the mouth which are produced 
are so objectionable that a preliminary extraction of teeth, 



292 TREATMENT OF MALFORMATIONS OF THE JAWS 

to be followed later by submucous resection of the bone, 
has been advised." 1 

The operation has also been performed by von Bergmann, 
Ballin 2 (see Figs. 242 and 243), Babcock, Cathcart, and 
others. The difficulties encountered by these pioneers has 
led to improvements in method. Figs. 244, 245, and 246 
show a skull exhibiting a typical deformity, with dotted 
lines and cuts drawn upon the ramus to indicate several 

Fig. 24G 




Correction according to section d-c. (After Babcock.) 

possible ways for resection, all of which are far enough 
removed from the body of the bone to exclude any possible 
involvement of the teeth. From these it can readily be 
seen that a correction of the deformities above referred to 
are quite within the range of surgery, and that they offer 
the only feasible plan for a cure. 

Dr. Blair 3 reports an original method of transplantation 



1 See Blair, Dental Era, April, 1907. 

2 Proc. Amer. Soc. Orthodontists, seventh annual report, 
s Jour. Amer. Med. Assoc, July 17, 1909, pp. 178 to 183, 



TREATMENT OF MALFORMATIONS OF THE JAWS 293 

Fig. 247 




Profile of Dr. Blair's patient prior to operation. 



Fig. 248 



SyfPfPP 




9 \Wrm^ 





ma %W^ 


y» 







Profile of Dr. Blair's patient after double resection and transplantation of 
costal cartilage. 



294 TREATMENT OF MALFORMATIONS OF THE JAWS 

of the curved part of the eighth costal cartilage, with its 
perichondrium, to the mental eminence of a chin in a patient 
suffering from mandibular micrognathism. This was for 
improvement of the facial lines, which a bilateral transverse 
section of the rami had previously failed to entirely correct. 
The vast improvement of the profile is clearly shown in 
Figs. 247 and 248. 

For a further elucidation of the subject the reader is 
referred to the original monographs enumerated above. 



INDEX 



Abnokmal frenum labium, 58, 61 
Accidents causing malocclusion, 74 
Acquired malocclusions. See Eti- 
ology. 
Adenoids, 69 

Age best for treatment, 138 
Alignment, definition of, 81 

variations of, 105 

wire, 147, 159, 160, 161, 176, 224, 
225 
Aluminum bronze for appliances, 

153 
Alveolar process, changes in, 183 
Alveolitis as a cause of malocclu- 
sion, 75 
Anchorage, definition of, 164 

extramaxillary, 170 

intermaxillary, 168 

intramaxillary, 167 

reciprocal, 166 

stationary, 165 
Angle's appliances. 149 

classification of malocclusion, 88 

system, 149 
Anomalies of eruption, 84 

of form, 58 

of the jaws, 84 

of number, 56 

of position, 63 

of structure, 84 

of the tongue, 65 
Appliances, 152 

Angle's, 149 

Case's, 163 

Farrar's, 148 

Fauchard's, 146 

Flagg's, 147 

metals used for, 152 



Appliances, Patrick's, 148 

Schange's, 146 
Arch form, correction of, 191 

maintenance of, 187 
Artificial nursing as a cause of 

malocclusion, 77 
Asymmetry of the jaws, 63 



B 



Bands, anchor, 156 
application of, 173 
attachments to, 157 
introduction of, 156 
kinds of, 156 
uses of, 156 
plain, 154 

application of, 175 
introduction of, 154, 155 
uses of, 154 
retaining, 186 
Beauty of form, definition of, 121 
Buccoversion, definition of, 92 
treatment of, 191 



Caries, prevention of, 36 
treatment of, 38 

Case contouring appliance, 163 
modification of, 197 

Cells of construction and destruc- 
tion, 183 

Cephalic index, 99 

Civilization as a cause of malocclu- 
sion, 78 

Cleansing of the teeth, 36 

Cleft palate as a cause of malocclu- 
sion, 61 



296 



INDEX 



Deciduous teeth, premature loss 
of, 66 
prolonged retention of, 67 
Dental index, 99 
Dentition, anomalies of, 84 
Diagnosis, definition of, 83 

methods of, 83 

nomenclature of, 83 

rules governing, 96 
Diseases causing malocclusion, 65 
Disharmonisms, causes of, 78 
Distoclusion, definition of, 89 

post-treatment maintenance of, 
189 

treatment of, 245 
Distoversion, definition of, 92 

post-treatment maintenance of, 
186 

treatment of, 198 
Disuse of teeth, 77 



Early treatment, reasons for, 130, 

137 
Elastic rubber bands, 163, 181 
Etiology of malocclusion, 52 

definition of, 52 

extrinsic factors, 66 

intrinsic factors, 55 

unknown factors, 77 
Examination of mouth, 32 
Extraction of teeth, 40 

evils of, 41 

rules governing, 41 



F 



Facial angle, 99 

deformities, 97 

diagnosis, 126 

harmony, 119, 122 

models, 48 

photographs, 49 
Farrar's appliances, 148, 149 
Fauchard's appliances, 146 
Flagg's appliances, 147 
Forces, anchorage of, 164 
Frenum labium, abnormal, 58 
causes of, 61 



German silver for appliances, 153 

texts. See Literature. 
Gilmer plain band, 155 
Gnathic index, 99 
Gold for appliances, 152, 153 



Habits causing malocclusion, 71 
Health as a factor in treatment, 

131 
Hereditary transmission, 53, 282 
Hyperplastic formation of connec- 
tive tissue, 77 



Impressions for models, 47 
Infraversion, definition of, 92 

treatment of, 208 
Intermaxillary anchorage, 168 
Intramaxillary anchorage, 167 
Iridioplatinum for appliances, 152 



Jackscrew for reciprocal anchor- 
age, 167 
for torsoversion, 205 
Jaws, asymmetry of, 63 
deformities of, 87 

prevention of, 85 
treatment of malformations of, 
284 



Kingsley's inclined plane, 255 

Oral Deformities, 21 
Knapp's system, 149 



Labioversion, definition of, 92 
post-treatment maintenance of, 

187 
treatment of, 192 

Lever for treatment of malocclu- 
sion, 163, 203 

Ligatures, 162 



INDEX 



297 



Ligatures, application of, 181 
Linguoversion, definition of, 92 
post-treatment maintenance of, 

187 
treatment of, 195 
Lip-biting as a cause of malocclu- 
sion, 73 
Literature of orthodontics, 20 
American, 21 
English, 22 
French, 22 
German, 22 
Spanish, 22 



M 



Macrognathism defined, 87 
Magill, plain band, 155 
Malalignment defined, 81 
Malformation of jaws, 85 

treatment of, 284 
Malocclusion defined, 81 

differentiation of, 85 
Malposition defined, 81 

kinds of, 92 

treatment of, 191 
Malrelation of the arches defined, 
85 

treatment of. See Distoclusion 
and mesioclusion. 
Mechanical formation of denture, 

77 
Megadont defined, 101 
Mesioclusion defined, 89 

treatment of, 272 
Mesioversion defined, 92 

treatment of, 201 
Mesodont defined, 101 
Mesognathous defined, 99 
Microdont defined, 101 
Micrognathism defined, 87 
Models, facial, 48 

plaster, 46 

uses of, 47 
Mouth, examination of, 32 



N 



Nasal obstruction, 67 
consequences and 
of, 69 



symptoms 



Neutroclusion defined, 94 

treatment of, 213 
Noble metals used for appliances, 

153 
Nomenclature of orthodontics, 19 
Non-occlusion defined, 81 



Obstetrical deformity, 74 
Occipital anchorage, 170 
Occlusion defined, 81 

importance of, 124, 138, 184, 
185 
Oral hygiene, 37 
Orthodontics defined, 17 

journals of, 23 

literature of, 20 

nomenclature of, 19 

postgraduate study in, 26 

practice of, 23 

societies of, 23 

specialization in, 24 

synonyms of, 17 

technique of, 26 
Osteoblasts, 184 



Pain, relief of, 35 

Palatal index, 104 

Patrick's appliances, 148 
system, 149 

Pericemental affections, 75 

Pericementum, fibers and functions 
of, 183 

Perversion defined, 92 
treatment of, 212 

Photographs, 49 

Plaster models, 46 

Platinum, uses of, 152, 153 

Predisposition, 53, 54 

Premature loss of teeth, 66 

Preparation of mouth for treat- 
ment, 31 

Profile, abnormal variations of, 
108 
normal variations of, 99 

Prognathous defined, 99 

Prognosis defined, 130 



298 



INDEX 



Prolonged retention of temporary 
teeth, 67 

Pulpless teeth requiring move- 
ment, 39 



Race admixture as a cause of 

malocclusion, 78 
Radiographs, 50 
Reciprocal anchorage, 166 
Records of treatment, 42 
Resorption in tooth movement, 183 
Retaining appliances, 186, 187, 

188, 189 
Retention defined, 184 

of arch form, 187 
relation, 189 

of tooth position, 186 

time required for, 185 
Rotation of teeth. See Torso- 
version. 
Rubber elastic bands, 163, 181 

vulcanite plates for retention, 187 



Schange's appliance, 146 

Sex, consideration of, in treatment, 

131 
Skiagraphs. See Radiographs. 
Skull cap, 163, 170, 171 
Supraversion defined, 92 

treatment of, 210 
Symphysis, variations of, 105 
Systems of treatment, 28 

Angle's, 149 

Case's, 149 

Farrar's, 149 

introduction of, 148 

Jackson's, 149 

Knapp's, 149 

Lukens', 149 

Patrick's, 149 



Technique of orthodontics, 26 
Thumb-sucking as a cause of mal- 
occlusion, 71 



Tissue changes caused by treat- 
ment, 183 
Tongue-sucking as a cause of mal- 
occlusion, 73 
Tonsils, hypertrophy of, 69 
Torso version defined, 92 

treatment of, 203 
Transversion defined, 92 

treatment of, 212 
Traumatism, 74 
Treatment of bucco version, 191 

of distoclusion, 245 

of disto version, 198 

of infraversion, 208 

of labio version, 191 

of linguo version, 195 

of malformation of the jaws, 284 

of mesioclusion, 272 

of mesioversion, 201 

of neutroocclusion, 213 

of perversion, 212 

records, 42 

of supraversion, 210 

of torsoversion, 203 

of transversion, 212 
Tube hooks, 162 
Tubes, buccal, 174, 178 
Turbinates, hypertrophy of, 69 



Variations of alignment, 102 
of the facial angle, 106 
of the head form, 97 
of lower third molars, 105 

Vulcanite plates, uses of, 187 



W 

Wire alignment, 147, 159, 160, 
161, 176, 224, 225 
ligatures, 162, 181 



X-rays. See Radiographs. 



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